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The primary role of the Utilization Review (UR) Nurse is to provide clinical support to the Utilization Management Department and Medical Director to assure that our members receive all appropriate medical services in compliance with medical and regulatory guidelines. Responsibilities include, but are not limited to, review and authorization of Outpatient Services, review of requests for pre-authorization of elective admission and procedures, inpatient admission review, review of continuing stay and discharge planning and coordination of care and services of select member populations with common chronic conditions. In all areas, the UR Nurse is charged with managing the delivery of care in an effective, professional and compassionate manner.


  • Review and evaluate all requests for elective inpatient admission
  • Authorizes those inpatient requests that meet the health plan s approved UM criteria and policies in the Clinical Services P&P Manual
  • Identify on a daily basis all MLTC members who are currently hospitalized
  • Conduct initial inpatient review and determine the appropriateness of admission, anticipated length of stay and potential discharge needs
  • Prioritize the review of patients according to the relevant Clinical Services Policy and Procedures
  • Accept telephonic and faxed reviews
  • Document the inpatient review in the computer system including diagnosis, procedures, attending physician, treatment plan, anticipated length of stay, and the Interqual Criteria used to justify continued stay
  • Perform concurrent review and enter information in the computer system in a timely manner Assess and coordinate referrals for inter-hospital transfers and specialty care
  • Appropriately and expeditiously refer cases to the Medical Director, process Medical Director s decision in the computer system
  • Generate Approval and Denial letters based on Medical Director s determination
  • Expeditiously alert providers by phone of denials
  • Appropriately refer cases to re-insurer in a timely manner
  • Actively participate in the discharge planning process with the facility discharge planner to ensure timely discharge, appropriate follow up and continuity of care
  • Facilitate requests for Sub-Acute care, DME, Home Health Care and Transportation
  • Refer cases with quality of care concerns to the Medical Director and Quality Improvement Dept.
  • Alert Provider Relations team regarding possible need to negotiate rates for Non-Par Providers, assure that all necessary paperwork is obtained, and appropriately document in the computer.
  • Tasks specific to Outpatient Services assignment (Specialist Authorization and Pre-certification of Ambulatory procedures)
  • Review and evaluate all requests for office visits, home care, outpatient procedures, ambulatory surgery and transportation according to MLTC's UM guidelines and the standards specified in the MLTC Utilization Manual & Accept telephonic and faxed reviews
  • Authorizes those requests that meet the health plan s approved UM criteria and the policies in the Clinical Services P&P Manual.& Appropriately document the review in the computer system including: diagnoses, procedures, specialists, treatment plan, and the Interqual Criteria used to justify the approval of request
  • Appropriately and expeditiously, refer cases to the Medical Director Process
  • Medical Director s decision in the computer system
  • Generate Approval and Denial letters based on Medical Director s determination.
  • Expeditiously alert provider of phone denials
  • Refer cases with quality concerns to the Medical Director and Quality Improvement Dept.
  • Alert Provider Relations team regarding possible need to negotiate rates for Non-Par Providers, assure that all necessary paperwork is obtained, and appropriately document in the computer
  • Assist members in accessing services, including making appointments for members when appropriate and providing patient teaching and support to facility compliance with treatment.
  • Must comply with all MLTC policies and procedures
  • Perform follow-up phone calls to facilitate obtaining of documents for any member visit or admission to Facilities, ER, Hospital
  • Maintain confidentiality of all member information in compliance with HIPAA requirements Accept and perform
  • Additional duties as assigned within the scope of Nursing knowledge and skills

  • Must have 1-3 years experience (MLTC preferred/UM and/or CM experience is a plus
  • ASN (minimum)/BSN Preferred
  • Must know EMR
  • NYS RN License
  • This position is 9am-5pm/in-office position with no remote work available.

Associated topics: care unit, domiciliary, infusion, maternal, mhb, neonatal, nurse rn, psychiatric, staff nurse, transitional

* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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