The nurse will perform utilization review activities, including Nursing Facility Level of Care reviews and Home Help quality assessments for Michigan Medicaid beneficiaries. They will also evaluate medical records, document findings, and participate in administrative hearings and appeals as necessary.
The Independent Review Specialist will conduct IDR/IIDR case reviews in compliance with CMS and URAC standards while managing assigned deliverables. They are responsible for accurate data entry, handling conflict of interest reviews, and ensuring the secure management of sensitive case information.
Review treatment requests and medical records to ensure medical necessity and compliance with workers' compensation guidelines. Prepare clear, objective, and timely review determinations while maintaining confidentiality and regulatory standards.
Conduct objective, evidence-based peer reviews of clinical cases to determine medical necessity and quality of care. Ensure all decisions are fair, unbiased, and submitted in a timely manner using provided IT systems.
Conduct objective, evidence-based peer reviews of clinical cases to determine medical necessity and quality of care. Ensure all decisions are fair, unbiased, and submitted in a timely manner using provided IT systems.
Conduct objective, evidence-based peer reviews of clinical cases to evaluate medical necessity and quality of care. Ensure all final determinations are fair, unbiased, and aligned with current clinical standards.
Conduct objective, evidence-based peer reviews of clinical cases to determine medical necessity and quality of care. Ensure all decisions are fair, unbiased, and submitted in a timely manner using the provided IT systems.
