Utilization Management Nurse (100% remote-Oregon RN License required)

• Review clinical information for medical necessity determinations of provider service requests for the inpatient and outpatient services.
• Perform initial and ongoing reviews for inpatient admissions, level of care, observation, pre-service, concurrent review and discharge planning in accordance with Customer’s inpatient policy and procedures, medical policy guidelines, MCG decision support criteria and CMS regulatory requirements.
• Process requests for prior authorization of outpatient services in accordance with Customer’s inpatient policy and procedures, medical policy guidelines, MCG decision support criteria and CMS regulatory requirements.
• Conduct all medical necessity clinical reviews in Customer’s care management platform for full transparency and tracking of Nurse activities and performance measures.
• Participate in department meetings, training, and audit activities equal to Customer employees.