Utilization Management Review RN

Hornet Staffing, Inc, a GEE Group company; United States; On-site; USD 70,000 - 95,000; Full time

Job summary

Hornet Staffing, Inc, a GEE Group company is seeking a healthcare professional to support utilization management and clinical review processes. The role emphasizes documenting decisions, organizing determination requests, and promoting evidence-based, cost-effective care.

The position requires collaboration with providers and internal teams to ensure appropriate service levels and patient safety. Ongoing knowledge of medical procedures and policies will be essential in daily duties.

Qualifications

• Utilization management knowledge as described in the posting.
• Effective communication with healthcare providers and internal staff.
• Awareness of compliance standards and regulatory requirements.
• Ability to handle multiple calls and queues within mandated requirements.
• Up-to-date medical and surgical knowledge relevant to healthcare delivery.

Responsibilities

• Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, procedures, and surgeries.
• Documents all relevant and specific information for determinations.
• Screens, prioritizes, and organizes determination requests per mandates and standards.
• Promotes cost effective care and quality toward cost containment measures based on evidence.
• Collaborates with providers and staff to promote appropriate service levels.
• Remains current with procedures, products, services, and enterprise policies.

Skills

Utilization Management

Communication

Compliance

Workflow

Medical Knowledge

Job description

• Utilization Management: Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards. Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.
• Communication: Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.
• Compliance: Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.
• Workflow: Proactively and efficiently work incoming and outbound calls and/or queues from multiple sources within mandated requirements.
• Knowledge: Remain current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.