The Utilization Management Nurse works collaboratively with the health care team to ensure proper utilization of medical services, procedures and care settings for individual members by assessing member needs and identifying solutions that promote quality and cost-effective care in the transition of care from the acute setting. The Utilization Management Nurse determines medical appropriateness for inpatient and outpatient services by evaluating medical information and applying established national criteria benefit determination, medical guidelines and compliance with state mandated regulations based on InterQual and other organizational tools. This includes concurrent reviews of inpatient/outpatient services, sub-acute care and prior-authorization reviews.
Job Specific Competencies:
Flexible Work Arrangement
Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.
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Neighborhood is an EOE M/F/D/V and an E-Verify Employer