RN Review Analyst
20500 Civic Center Dr Southfield, MI 48043
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.