Utilization Management Nurse Specialist

The Utilization Management Nurse Specialist is responsible for conducting clinical reviews to ensure services meet clinical criteria. They coordinate and document all aspects of utilization and benefit management. Responsibilities include validating medical documentation, consulting with medical directors, and identifying members who may benefit from case management services. The role also involves conducting retrospective medical claims audits, covering coding and DRG reviews, and referring cases for Quality Management when quality-of-care issues are identified. The Prior Authorization Nurse is responsible for reviewing requests for pre-service and concurrent services, supplies, and procedures. This includes inpatient hospitalizations, diagnostic testing, outpatient procedures, home health services, durable medical equipment, and rehabilitative therapies. The nurse integrates coding principles and monitors trends in utilization, identifying potential quality-of-care issues. Effective communication with providers and PHP medical directors is essential, and the nurse must meet departmental turnaround times and maintain high productivity and quality standards. In performing review and evaluation, the nurse assesses prior authorization requests, thoroughly reviewing clinical documentation to determine medical necessity and make informed authorization decisions. They document review outcomes accurately in electronic health records and case management systems. The nurse collaborates closely with healthcare providers, clarifies requests, gathers additional documentation, and ensures strict adherence to regulatory guidelines. They also participate in quality assurance initiatives and identify areas for improvement, supporting the efficient management of prior authorization processes.