Concurrent Nurse Reviewer, Facility Utilization Review Unit
HMSA · Honolulu, HI
Applies appropriate medical necessity criteria from established medical policies and clinical practice guidelines to apply concurrent review determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes determination of inpatient hospital stays as medically appropriate for the member's clinical condition or whether the stay requires referral to a Medical Director for potential denial. The Nurse Reviewer must follow each line of business requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each inpatient admissio
