Job Description

Your role in our missionReviews and interprets medical records and compares against criteria to determine appropriateness and reasonableness of care; apply critical thinking and decision making skills to determine if the medical record documentation supports the need for service while maintaining production goals and quality standards.Document decisions and rationale to justify review findings or no findings.Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail and completed within contractual deadline.Performs prior authorization, precertification, and retrospective reviews and prepares decision letters as needed in support of the utilization review contractAssists management with training new Nurse Reviewers to include daily monitoring, mentoring, feedback and education.