Utilization Review Nurse - - Rancho Cucamonga California

Location: Rancho Cucamonga, California
Posted On: 11/15/2024

Great opportunity for a Utilization Review RN.



Required Skills:



?Approves requests for medical services (inpatient, pre-certification and concurrent, and outpatient) based on available information, utilizing nationally accepted guidelines for utilization management (InterQual) as well as standard of care information and clinical judgment as appropriate.



?Requests clinical information when needed and refers the request to secondary medical review with the appropriate information, when approval for the request cannot be given by the nurse.



?Identifies need for referral of the member to case management and/or disease management services based on established referral criteria or individual care need identified during interaction with members or providers.



?Follows established policy and procedures for timely medical necessity review, escalation, Peer Review and appeals meeting all state, URAC and applicable regulatory guidelines.



?Serves as a facilitator to providers for resolution of provider concerns, complaints and grievances.



?Maintains and ensures the confidentiality of all information collected during the review process.



?Participates in medical necessity, URAC, clinical and quality training programs as requested.



?Communicates with providers and members as needed.



?Maintain a positive professional and respectful attitude with peers and clients.



?Determine and monitor appropriate discharge plans for all approved services.



We are an equal employment opportunity employer and will consider all qualified candidates without regard to disability or protected veteran status. More...

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