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Utilization Review Nurse

South Sacramento, California | Temp-to-Hire Position

Post Date: 07/06/2017 Job ID: 38534.1 Industry: Healthcare/Medical
We are currently recruiting for a Utilization Review Nurse for a well-known Healthcare Center in Sacramento. The Utilization Review Nurse will be responsible for evaluating authorization requests and authorize, modify, or pend per appropriate criteria. In addition, they will refer authorization requests not meeting criteria to specialty physician reviewer. This is a temporary to hire opportunity.

Responsibilities: Responsible for managing care from admission through discharge for assigned patients either inpatient or outpatient. Proactively assesses all potential case management and CCS member cases and actively manages all high risk, high volume cases throughout the continuum of the members health care needs or until they reach a maintenance mode. Researches and refers members to sources for alternative funding, community services and other services which may provide support to the patient and family. Tracks all CCS referrals for timely notification of decisions. Assists Medical Director with CCS appeals as applicable. Identifies cases for possible peer reviewers to evaluate the appropriateness and necessity of care and or quality of care concerns. Assures referrals are complete and enrollment/eligibility benefits verified, prior to authorizing inpatient and outpatient care. Performs concurrent review (possibly onsite)for inpatient and/or outpatient and case management to ensure appropriateness of admission. May collect and report utilization data and quality information. Review Requests for Authorizations and approve and/or refer to Medical Director/Chief Medical Officer for review and denial/modification. Applies managed care techniques to clinical practice within established criteria. Provides instruction to hospitalized members and their families; and serves as liaison between the member, the physician, the hospital and the Plan. (Inpatient Only). Authorize home health visits as needed; arrange for admissions to ancillary medical facilities, and secure other specialty services as needed under the supervision of the attending physician. (Inpatient Only). Authorize outpatient services requested, determine medical necessity; specialty services, carve out services etc. (Outpatient Only). May also refer to socia

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