POSITION |
SALARY |
INDUSTRY |
LOCATION |
TYPE |
REF # |
Nurse Case Manager |
OPEN |
Insurance |
Toronto |
Permanent |
803016O |
POSITION DESCRIPTION |
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The Utilization Review Specialist performs telephonic review of clinical services.
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This review will determine the medical necessity as well as alternative levels of care, utilizing clinical expertise, judgement and established criteria.
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REQUIREMENTS |
- Bachelors Degree or equivalent
- 3 or more years of related experience.
- Must be a registered nurse with a minimum of 3 year clinical experience in medical, surgical, orthopedic, neuro-surgery or psychiatric nursing.
- Demonstrated knowledge of medical criteria.
- Computer literacy.
- CPUR preferred.
- Reviews and monitors the medical treatment plans of injured parties.
- Applies clinical expertise, nursing judgment and established medical criteria to determine medical necessity of care proposed.
- Review information in medical record; obtain and review information from patient, physician and other participants in the care of patient; determine whether care of patient is an exception to established criteria for the diagnoses and problems that apply to that patient.
- Review process and outcome of medical care by comparing actual care of individual patient with criteria of care established of the appropriate medical service.
- May report on any adverse event or product complaint discovered through patient interaction.
- Elevate to Medical Director cases not meeting criteria in a timely manner according to Best Practices.
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