RN Review Analyst

Southfield, MI 48043

Posted: 03/18/2019 Category: Registered Nurse Job Number: 25805

Job Title: Utilization Review Nurse

Location:  Southfield, MI

Max Pay Rate: $32

Contact: Aaron Smith at A-Line Staffing - 877-782-3334 x234

Registered Nurse Utilization Review:

Responsible for the approval or rejection of claims, admissions approvals, telephone triage, and/or benefit interpretation. May be required to enter or reference data via PC and/or CRT terminal.

Registered Nurse Job Description
  • Educate member services and members/providers on Medicare policy and member benefits.
  • Assist with answering questions, supplying information and training on UM program (internal and external)
  • Assess member health needs consistent with clinical standards and practice to provide appropriate clinical recommendations.
  • Analyze and evaluate clinical documentation to resolve member inquires as to UM decisions and appeals/grievances
  • Identify and analyze UM/Claims issues pertaining to UM program to ensure correct reimbursement for covered/and or approved services – identify strategy to resolve and or devise solutions to mitigate any gaps identified
  • Utilize knowledge of approved resources, programs, product and tools to provide member with appropriate services
  • Work with cross functional teams to resolve issues/concerns/inquiries
  • Compile, analyze, develop and report data based on member and provider inquiries

Registered Nurse Requirements:
  • Registered Nurse with current Michigan RN  license.
  • Associate Degree or nursing diploma required.
  • Two (2) years patient care experience.
  • Triage, case management and/or rehabilitation experience preferred.
  • Expertise in the use of medical terminology.

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