Job Description
The Utilization Management Nurse Specialist is responsible for conducting clinical reviews to ensure services meet clinical criteria and are delivered appropriately. This involves coordinating, documenting, and communicating all aspects of utilization and benefit management, handling prospective and retrospective care reviews.
Responsibilities include validating medical documentation, consulting with PHP medical directors on cases that do not meet criteria, and identifying members who may benefit from case management.
The role also includes retrospective medical claims audits, covering coding and DRG reviews, medical necessity assessments, and referring cases for quality management. Additionally, the nurse may perform on-call duties and streamline the prior authorization process, supporting optimal patient outcomes.
About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve as a locally owned, not-for-profit healthcare system.