- Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
- Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members
- Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care
- Communicates with providers and other parties to facilitate care/treatment
- Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
- Participates in care rounds
- RN with an unrestricted licenses.
- 3+ years clinical practice experience, e.g., hospital setting,
- alternative care setting such as home health or ambulatory care required.
- Utilization Management experience