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Must be familiar with Med compass system documentation. Familiar with Medicare and Medicaid.

Must be familiar with CMS criteria

Responsible for the review and evaluation of clinical information and documentation.

Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.

Independently coordinates the clinical resolution with internal/external clinician support as required.

Requires an RN with unrestricted active license

Prior Authorization UM Nurse Consultant

Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.

Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care.

Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

3-5 years of clinical experience required- Managed Care experience preferred

Knowledge of UTILIZATION MANAGEMENT principles with Prior Authorization experience preferred.

RN with current unrestricted state licensure