Conduct prospective, concurrent, and retrospective medical necessity reviews for post-acute care services, including appeals, to help determine the appropriate setting and length of stay. Support discharge readiness, transition planning, and alternative care recommendations for members who may not need post-acute care services.
Key Responsibilities
- Conduct medical necessity reviews using established medical policy, guidelines, and InterQual criteria.
- Review prospective, concurrent, and retrospective post-acute care requests for appropriate setting and length of stay.
- Coordinate care across the health care continuum and support member outreach.
- Provide alternative care support for members not appropriate for post-acute care services.
- Support discharge readiness for members transitioning to a lower level of care.
- Review appeal requests initiated by providers, facilities, and members.
Required
- Current unrestricted Michigan Registered Nurse license.
- Clinical experience in post-acute care, home care, acute patient care, discharge planning, case management, utilization review, or related settings.
- Demonstrated clinical knowledge of patient care and health care delivery processes.
Preferred
- Bachelor’s degree in nursing, allied health, business, or a related field.
- Two to four years of clinical experience.
- Experience caring for older adults in the home or post-acute care setting.
- Health insurance plan or managed care experience.
- Experience with InterQual criteria.