Utilization Management Nurse (UM RN) - Community Health Choice
The UM RN will perform utilization review of Community members requiring authorization for health services. The UM RN will help ensure proper data entry of authorization in the managed care platform, and initiate the approval process for requested services/treatments utilizing nationally recognized evidenced based clinical criteria and/or internal policies, protocols, and procedures. The UM RN will screen and review clinical information for the most appropriate service areas within Community; making referrals to high risk perinatal team, complex case management and disease management. The UM RN will work closely with the Medical Directors and refer requests that do not meet medical necessity criteria. The UM RN has heavy telephonic and facsimile contact with providers and
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