Job Description

Nurse Reviewer -Utilization Management / Prior Authorization

3-6+ Month Contract / Temp to Perm

Compact License Required

• Determine medical appropriateness of services following evaluation of medical guidelines applying evidenced-based InterQual® criteria, Medical Policy and benefit determination.
• Perform utilization review activities, including pre-certification, concurrent and retrospective reviews according to guidelines.
• Determine medical necessity of each request by utilizing approved evidenced based guidelines / criteria
• Utilize decision-making and critical-thinking skills in the review and determination of coverage
• Reviews, documents, and communicates all utilization review activities and outcomes
• Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines

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