In this role, the clinician performs prospective, concurrent, and retrospective medical necessity reviews for post-acute care services, focusing on appropriate level of care, length of stay, and appeal requests. The work also includes member outreach and support for members transitioning to a lower level of care when post-acute placement is not appropriate.
Key Responsibilities
- Conduct medical necessity reviews for post-acute care services using established medical policy and guidelines.
- Review prospective, concurrent, and retrospective cases to determine appropriate setting and length of stay.
- Coordinate care across the health care continuum, including outreach to members.
- Support alternative care planning for members who do not meet criteria for post-acute care.
- Formulate discharge readiness for members transitioning from post-acute care to a lower level of care.
- Review appeal requests initiated by providers, facilities, and members.
- Use InterQual criteria and related utilization review processes.
Required
- Current unrestricted Michigan Registered Nurse license.
- Registered Nurse (RN) credential.
Preferred
- Bachelor’s degree in nursing, allied health, business, or a related field.
- Two to four years of clinical experience.
- Experience in post-acute care, home care, acute care, discharge planning, case management, or utilization review.
- Experience caring for aging populations in the home or post-acute setting.
- Experience with InterQual.
- One year of health plan or managed care experience.