4/18/2024 0 Comments Nurses resume templateMay provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses Sends appropriate system-generated letters to provider and member Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turn around times Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care servicesĪnswers Utilization Management directed telephone calls managing them in a professional and competent manner Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelinesÄetermines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |