Utilization Review RN

Job Title: RN Review Analyst
Location: 100% Remote
Duration: 10+ Months
License Required: Active & unrestricted MI RN license

Job Summary
Perform prospective, concurrent, and retrospective review of inpatient, outpatient, ambulatory, and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service, and level of care, including handling appeal requests initiated by providers, facilities, and members. May establish care plans and coordinate care through the health care continuum, including member outreach assessments.

Key Responsibilities:

· Conduct prospective, concurrent, and retrospective reviews of patient services.

· Ensure medical necessity, appropriate length of stay, intensity of service, and level of care.

· Handle appeals from providers, facilities, and members.

· Develop and implement care plans as needed.

· Coordinate care through the health care continuum and perform member outreach assessments.

Qualifications:

· Bachelor’s degree in Nursing, Allied Health, Business, or related field preferred.

· Two (2) to four (4) years of clinical experience, which may include:

o Acute patient care

o Discharge planning

o Case management

o Utilization review

· Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.

· One (1) year health insurance plan or managed care environment experience preferred.

· Registered Nurse with current unrestricted Michigan RN license required.

· Certification in Case Management may be preferred based upon department assignment.

Requested Criteria / Preferred Skills:

· Minimum 2 years acute care experience with an unrestricted RN license.

· ICU/ER experience preferred; for post-acute care positions, experience in SNF/Rehab/LTACH preferred. (Should not be just 2 years in a specialized field.)

· Experience with InterQual, MCG, or other utilization review tools.

· Advanced computer skills.

· Typing speed of 40+ WPM.