RN, Targeted Review

Responsible for precertification and medical necessity reviews on designated referrals, targeted outpatient procedures, services, and inpatient admissions. Activities include telephonic review using established criteria, retrospective ED reviews, eligibility and benefit reviews, identification of patients for case management, quality improvement reviews, and communication with care coordinators, case managers, members, providers, and other departments. Utilizes criteria to perform precertification and referral reviews within required timeframes, refers non-approved cases to review physician, performs questionable benefit reviews, and provides correspondence to members. Interacts with physicians to ensure appropriate resource utilization, establishes contact with patients and families for education, refers to home care or social workers as needed, and ensures appropriate level of care. Performs quality of care reviews, assists with physician education, reviews utilization statistics, and maintains knowledge of regulations and criteria. Documents medical necessity, diagnoses, procedures, and demographic data. Issues non-coverage letters. Works cross-functionally to meet organizational goals.