RN CLINICAL REVIEWER
Performs utilization review in accordance with all state mandated regulations. Maintains compliancy with regulation changes affecting utilization management. Reviews patients' records and evaluates patient progress. Performs continuing review on medical records and identification and need of on-going hospitalization. Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct review. Reviews and validates physician's orders, reports progress and unusual occurrences on patients. Ensures appropriate and cost-effective healthcare services to patients. Documents review information in computer. Communicates results to claims adjusters. Prepares information for notification letters for providers and employees. Receives and processes requests for appeal of denials. Responds to complaints per UR guidelines. Maintains Utility review and appeal logs, as needed, by jurisdiction. Performs administrative duties; receives, logs in and fi
