Utilization Management Nurse - Affinity Health Plan : Job Details

The Utilization Management Nurse will conduct reviews of current inpatient services, and determine medicalappropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination in accordance with Utilization Management policies and procedures. ESSENTIAL FUNCTIONS Perform utilization management, utilization review, or concurrent review (on-site at a hospital, or telephonic inpatient care management) of hospitalized members ensuring medical necessity, appropriateness of admission, and continued stay following evaluation of medical and benefit determination guidelines. Maintains compliance with all state mandated regulations. Collaboration with hospital staff, physicians, care/service coordinators, plan Medical Director, members and their families to provide the level of care necessary to meet members health needs. Maintain an active role in assuring the continuity of care for all inpatients through early discharge planning and working w...Management, Nurse, Medical Director, Patient Services, Microsoft, Evaluation, Healthcare