Description:

　　This position is responsible to evaluate member specific clinical information against objective, standardized criteria to determine medical necessity, appropriateness, and efficiency of specific services the organization has targeted for prior authorization. Identify care management needs and refer members to care management as appropriate.

　　·​ Complete the continuum of the utilization review processes within the established department turnaround times including: first level medical necessity review, consultation with Medical Directors and/or healthcare providers, and/or facilitate peer to peer discussions when applicable.

　　·​ Review medical records as part of prior authorization review for services and/or review of acute care admissions and concurrent length of stay review.

　　·​ Partner with healthcare providers to assess member’s discharge needs for post-acute care, actively participate to assist with transition of care, and to establish care support.

　　·​ Refer cases to Case Management for potential case management activities based on identified member needs or utilization specific concerns.

　　·​ Develop a comprehensive knowledge of member benefits for each product; understand, implement, and support the Evidence of Coverage, and follow organization policies as they relate to member benefits.

　　·​ Provide medical necessity review for published authorization strategies, medical policies, review criteria, review standards, and regulatory requirements in the application of the utilization review process.

　　·​ Understand and support the organization’s provider network and contracts.

　　·​ Document review activities in accordance with professional nursing and established organizational standards.

　　·​ Participate in Holiday On-Call Coverage and monthly late nurse rotation.

　　·​ Participate in and pass Annual Regulatory Inter-Rater Reliability testing.

　　·​ Collaborate with claims, provider assistance center, and provider relations and contracting in ad hoc provider education.

　　Skills:

　　RN, Medicare, Utilization Review, acute care

　　Additional Skills & Qualifications:

　　Registered Nurse, BSN preferred

　　Two years acute care clinical experience or a minimum of 3-5 years’ experience in a post-acute care setting.

　　Experience with Case Management/Utilization Review Experience with Interqual

　　Active MN Licensure

　　Experience Level:

　　Intermediate Level

　　About Actalent

　　Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

　　Diversity, Equity & Inclusion

　　At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

　　Hiring diverse talent

　　Maintaining an inclusive environment through persistent self-reflection

　　Building a culture of care, engagement, and recognition with clear outcomes

　　Ensuring growth opportunities for our people

　　The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

　　If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email [email protected] (%[email protected]) for other accommodation options.