Referral or Utilization Management RN

Sterling Medical has provided comprehensive healthcare services, including healthcare staffing, healthcare departmental operation, and healthcare clinic operation, since the company’s commencement of such services in 1980.

* This Registered Nurse will provide Referral Management activities, include timely processing of Right of First Refusal (ROFR) requests, screening of specialty care referrals, sustaining up-to-date Specialty Clinic Booking Guidance, MTF Capabilities Report, ROFR Reports, maintaining up-to-date MTF/Managed Care Support Contract (MCSC) Memorandums of Understanding (MOU's), comply with Referral and Authorization Business rules, tracking, accounting, and resulting of referrals, and full use of RM information management systems. * Individual will conduct reviews for medical necessity, pre authorization, medical appeals, collection and recovery from insurance carriers, and right of first refusal activities.

**Mandatory knowledge and skills:** * Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines. * Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care Systems referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution. * The Contractor must have a working knowledge of Ambulatory Procedure Grouping (APG"S), Diagnostic Related Grouping (DRG's), International Classification of Diseases-Version 9(ICD) and Current Procedural Terminology-Version 4 (CPT-4) coding. * Possess excellent oral and written communication skills, interpersonal skills, and have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows. **EDUCATION:** * Baccalaureate of Science in Nursing Program from an apporved National League of Nursing. **LICENSE/CERTIFICATION:** * Current, active, full and unrestricted License to practice Nursing in accordance with State Board requirements. Nurse applicants must be a current U.S. licensed Registered Nurse. * License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency. **EXPERIENCE:** * Six years of clinical nursing experience is required. One year of previous experience in Utilization Management is required. Full time employment in a nursing field within the last 36 months is mandatory. * Equivalent combinations of education and experience may be qualifiying if approved by the requesting location and the Contracting Officer. If education or experience is used to meet the specialized requirements of this position, it must be directly related to referral/utilization management.