Performs review activities as outlined following rules established by the peer review organization, Medicare, and other third-party payers. Coordinates utilization functions and personnel to comply with procedures and regulations.   Assists in monitoring medical staff to ensure quality care and appropriate utilization of services and compliance with length of stay guidelines.  Participates in the discharge planning process and identifies appropriate resources both internal and external required for a successful transition of care to an alternative setting.

Responsible for the effective and sufficient support of all utilization activities according to policies and procedures. Refers cases to the Medical Director as appropriate. Evaluates and refers cases to the quality of care and chronic case improvement programs as needed. Assists with discharge planning. Maintains strong working relationship with internal and external customers and professionally communicates information as needed or required. Documents information into the computer system. Supports IPA/POD meetings by providing data and identifying improvement opportunities.

Minimum Requirements:  Current licensure as a Registered Nurse (RN) or licensed mental health practitioner.  At least three years clinical experience with at least two years in utilization review.  Knowledge of ICD-9 and CPT coding guidelines and InterQual Criteria for utilization review.

Preferred Requirements:  Managed care experience.

HealthSpring, Inc. is an EEO/AA employer.