UM RN Reviewer

Core Job ResponsibilitiesPerform medical necessity reviews using InterQual and/or other medical decision support software designated by the organization and rendering determinations appropriately within established regulatory documents required information into necessary systems according to department documentation standards and following all department workflows including correspondence to members and providers (ie. PCP notification of inpatient admissions). Documentation of discharge planning within 24 to 48 hours of admission notification. Completes admission authorization out of network transfers initiates concurrent authorization completes retrospective authorization and minimizes financial risk by maintaining timely communication with all payors. Generates and process daily admission logs and appropriate denial letters as per UM critical analysis of decisions/determinations while supporting effective team collaboration and with audit adhere to corporate compliance policy department guidelines/policies and all applicable laws and with the Case Management/Care Coordination nurses to ensure members who are eligible for case management are identified and enrolled as well as to ensure contact post hospital discharge. Works closely with the health center staff providers hospitals MCOS and other outside vendors concerning scope of benefits referrals precertification/authorizations and network facility participation. Participate in department committee meetings webinars training projects and special assignments for cross-coverage purposes to meet strict authorization processing deadlines. Other duties as required; Bachelors (Preferred); Registered Nurse (RN); current licensure in Illinois Minimum 1-year nursing experience inpatient or ambulatory (Preferred) Minimum 1-year Utilization Management experience preferred Minimum 1-year Case management experience preferred Experience with Epic System (EHR) InterQual a plus Intermediate proficiency in Microsoft Office products