Utilization Management Nurse I

Utilization Management Responsibilities:

• Provide members and providers with timely prior approvals by obtaining necessary medical information.
• Complete post-service reviews for medical necessity.
• Provide precertification and continued stay reviews, assisting with timely discharge plans.

Collaboration and Communication:

• Work with healthcare provider staff professionally, gathering medical information and facilitating discharge planning.
• Collaborate with providers to resolve conflicts and utilization review issues.
• Interact with Wellmark Medical Directors and Physician Reviewers as needed.

Documentation and Compliance:

• Document review processes and decisions accurately, consistently, and timely within the review system.
• Comply with regulatory standards, accreditation standards, and internal guidelines.
• Meet quality assurance and production metrics for the utilization management unit.