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Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing healthcare members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Duties: Review cases for in patients/in hospital: skilled care, acute rehab and long term acute care. Nurses working at the facilities members are being cared for, will be sending over clinical information to be reviewed by the Care Review Clinician. Therefore, this agent will not be traveling and will be reviewing information at the office.

• Utilization Review in hospital setting. • Prior author experience. • Inpatient hospital experience. • Nurses who are used to doing both production and review work. • RN required. • Millemen is a MUST. • Interqual is PLUS. • Good clerical experience. • Insurance experience PLUS. • Required Experience: Minimum 3-4 years of clinical practice in hospital setting. • 1+ year utilization management, and/or case management. • Required Licensure/Certification: Active, unrestricted State Nursing (RN) license in good standing.

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