Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments. Two (2) of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc. Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes. One (1) year health insurance plan experience or managed care environment preferred. Registered Nurse with current unrestricted Michigan Registered Nurse license required. Other requirements: Associate Degree or nursing diploma required, Triage, case management or utilization review experience, Expertise in the use of medical terminology, InterQual knowledge preferred and some weekends and corporate holidays.

Top 3 Required Skills/Experience –

• 2 years acute care experience with an unrestricted Registered Nurse license

• ICU/ER preferred *should not just be 2 years in a specialized field such as NICU/OB/BH/Substance Abuse *

• InterQual/MCG or other utilization review experience preferred

Required Skills/Experience – The rest of the required skills/experience. Include:

• Advanced computer skills

• 40+ WPM typing

• Good verbal and written communication skills

• Good organizational skills

Preferred Skills/Experience – Optional but preferred skills/experience. Include:

• Utilization Review experience at a previous insurance company (medical, surgical admissions)

• Utilization Review experience in an acute care setting

Education/Certifications – Include:

• Must be a RN with a current and unrestricted Registered Nurse license

Category Benefits

Function HR / Benefits

Req ID JN -122024-121784