The Utilization Management (UM) Nurse is responsible for conducting medical necessity reviews up to 12 hours per day, utilizing Indicia for Case Management, and performs clinical reviews through document review, discussion with physicians and collaboration with the care team on the coordination of safe transitions of care.
- Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG).
- Ensures timely identification of need and referral for alternative level of care.
- Responsible for timely and accurate certification/authorization of hospital admissions and hospital days.
- Provides required information to payors in a timely fashion and obtains appropriate authorization for all days.
- Monitors and evaluates patient/clients ongoing plan of care and conducts timely concurrent reviews based on set standards.
- Associates Nursing
- Diploma (Nurse)
- Bachelors Nursing
- Nice to have: Bachelors Nursing