Clinical Utilization Review RN

Under general supervision of the Director of Case Management, the Utilization Review Nurse provides a clinical review of cases using medical necessity criteria to determine the medical appropriateness of inpatient and outpatient services. Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. Provides ongoing communication with the health plan, clinical providers (HMH Physicians/NPs) and care coordination departments regarding medical necessity for prospective, concurrent, and retrospective reviews. Collaborates as a team to ensure that medical records support the level of services being delivered.

ESSENTIAL JOB FUNCTIONS

Every effort has been made to make this job description as complete as possible.  However, it in no way states or implies that these are the only duties the incumbent will be required to perform.  The omission...