Travel Nurse RN - Utilization Review
Baltimore, MD
GQR Healthcare
5x8 hrs, Days

Shift: Mon – Fri, 8:00am-5:00pm EST

WORK  Location- REMOTE

No Call. holiday or weekend

There is no direct patient care, this is a medical review position only.

Required: Active RN License, (5) years RN experience, Current UR experience; EPIC  and  referral platforms such as NaviHealth  or AllScripts. Knowledge and use of Proficiency using InterQual and/or Milliman criteria software systems,   Managed care experience in utilization review for at least 1 year preferred.

Duties: Responsible for the day to day management of health confined plan members in acute care and/or rehabilitative facilities. The Utilization Nurse (UN) actively monitors the appropriateness of care received by plan members in a variety of settings, acute hospital, sub-acute hospital, and acute rehabilitation facility. The Utilization Nurse applies member benefit and medical criteria to determine authorization of services in coordination with the Medical Directors. The Utilization Nurse proactively initiates discharge planning for of members, including identification of post-discharge needs and coordination of post discharge referrals/services. The UN communicates verbally and in writing authorization and/or denial of covered services with providers, facilities and members. The UN is a member of administrative and clinical teams in the area of assignment. Clinical knowledge is maintained and updated and UN must maintain acceptable documentation and quality standards.

Skills: Excellent verbal and written communication skills to effectively interact and work correctively with enrollees, Physicians facility staff and management staff. Work requires excellent interpersonal skills and attitude to effectively project a positive image of our Managed Care Program. Computer skills working with a variety of applications and online systems. Knowledge of Enterprise and utilizing various criteria sets i.e. InterQual. Ability to negotiate and resolve conflicts with external customers.