Utilization Review RN

• Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs, or community resources.
• Applies clinical knowledge to work with facilities and providers for care coordination.
• Works with medical directors in interpreting appropriateness of care and accurate claims payment.
• May also manage appeals for services denied.
• Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

• Must have clear and active RN license in the state of IN
• AS/BS in Nursing or combination of education / experience
• 2 years of experience in an acute care clinical environment
• Strong computer skills/ability to navigate multiple systems (MS Outlook/Word/Excel)
  

Advantages of this Opportunity:

• Competitive salary
• Fun and positive work environment
• Medical benefits offered

Interested in being considered? 

• Apply now for immediate consideration! You may contact Christine Morta at (407) 233-0769.