Company Description Integrated Resources, Inc is a premier staffing firm recognized as one of the tri-states most well-respected professional specialty firms. IRI has built its reputation on excellent service and integrity since its inception in 1996. Our mission centers on delivering only the best quality talent, the first time and every time. We provide quality resources in four specialty areas: Information Technology (IT), Clinical Research, Rehabilitation Therapy and Nursing. Job Description Principal Accountabilities: • Evaluates clinical information submitted by providers against plan review criteria and benefit guidelines. • Utilizes clinical information to determine if criteria for medical necessity and benefit guidelines are met. • Utilizes professional judgment to determine if additional information is required, then follows through to obtain additional information prior to making a decision. • Documents all pertinent case information and dispositions for approvals and denials. Refers all cases failing to meet interqual medical necessity criteria to Medical Director for review and final determination. • Communicates with providers to initiate/coordinate outpatient services/discharge planning needs for members. • Acts as a liaison to assure services are provided in the least restrictive, most cost effective and clinically appropriate setting. • Works with the Utilization Management Manager, the Medical Director and providers to ensure that complete medical information is available to allow utilization management decisions to be made within The Plan’s standards for decision making. • Identifies potential members who may benefit from case management services and facilitates referral to the program. • Identifies and resolves any problems that could interfere with provider’s continuity and coordination of care of members and refers unresolved problems to Manager. • Creates and maintains monthly reports on inpatient activities. • Performs other related duties and projects as assigned. • Adheres to ACFC policies and procedures. • Supports and carries out our Mission & Values Qualifications Position Qualifications/Requirements: Education and Training: Associates RN degree required, Bachelor’s degree preferred. Experience: • Two years of experience in managed care quality assurance or utilization review. preferred • RN must have two years of experience in an acute care hospital. Additional Information Riya Khem Life Science Recruiter Integrated Resources, Inc. IT Life Sciences Allied Healthcare CRO Certified MBE |GSA - Schedule 66 I GSA - Schedule 621I DIRECT # - 732 -844-8721 | (W) # 732-549-2030 - Ext - 311 |(F) 732-549-5549