Utilization Review Nurse

<span id="job_summary" class="summary">We are looking for the best and the brightest problem-solvers who are dedicated to changing the way health care is delivered and are passionate about creating a better model for our national health care system. We offer a professional working environment, competitive salaries and excellent benefits. As we continue to grow, we are seeking an experienced Utilization Review Nurse to join our Detroit, Michigan, office. <br /></span>

Corporate Office in Detroit, MI

Healthcare Company

Our task is to make sure that you and your eligible family members are enrolled and receiving Medicaid or Alliance Benefits. Our mission is to help our D.C. neighbors receive the care and services needed to lead a long and healthy life. http://www.trustedhp.com/

keywords: quality assurance,medical,teamwork,planning,management,quality assurance,analysis,license,experience,degree


Competitive Salary & Benefits

Overview: This position is responsible for ensuring medically appropriate and necessary, high quality, cost effective care throughout the UR process within the THP Network.
Responsibilities: <ul> <li>Performs on-site and or telephonic review of acute and sub-acute services.</li> <li>Predicts and plans for patients&rsquo; needs from pre-admission, through acute, sub-acute care and post-discharge.</li> <li>Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of diagnostics, procedures, treatment and discharge planning.</li> <li>Acts in conjunction with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate levels of care, evaluates the continuum of care, identifies alternative health care service needs, matching members care needs with available resources&nbsp; in the respective care setting(s)</li> <li>Contacts appropriate discharge planning team members, facility utilization management department, physicians and other members to ensure timely coordination of discharge planning.</li> <li>Acts in conjunction with the clinical team related to discharge planning or transitional care (e.g. home care, hospice care, rehabilitation therapy/ care, PT/OT/speech; special program care</li> <li>Participates in Quality Improvement Process; tracks and reports trends re: inappropriate utilization of resources to the Chief Medical Officer; identifies and reports quality and or utilization issues to the Chief Medical Officer.</li> <li>Documents all activities in the appropriate system on a timely basis.</li> <li>Participates in rounds with the Chief Medical Officer. Reviews health plan, appeal items for concurrent and retrospective reviews as required and requested.</li> <li>Monitors and facilitates appropriate utilization of resources using clinical criteria.</li> <li>Participates on a multi-disciplinary clinical team to achieve positive member outcomes; Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.</li> </ul>
Requirements: <ul> <li>BSN required.</li> <li>Michigan active RN License required.</li> <li>Medicaid/managed care experience preferred.</li> </ul>