Nashville, TN

What you'll be doing

Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract. Consults with clinical reviewers and/or medical directors to ensures medically appropriate, high quality, cost effective care throughout the medical management process. Collaborates with providers to assess members needs for early identification of and proactive planning for discharge planning. Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications. Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

What your background should be

2 years of acute care clinical experience or any combination of education and experience, which would provide an equivalent background. Managed care or hospital based utilization management/case management experience required. Knowledge of interqual criteria required. Current unrestricted rn license in applicable state(s) required.

Required Schooling / Training

Requires an AS/BS in nursing.

Who is the client company

This is one of the largest for-profit managed health care companies.
If you are interested in this position, send your resume to