Utilization Review Nurse - Remote

Overview

The Utilization Review Nurse is responsible for the medical necessity review of outpatient services that require prior authorization, and/or management of concurrent inpatient admissions.

In Short

• Performs inpatient and outpatient utilization reviews using evidence-based guidelines.
• Evaluates severity of illness and intensity of service at time of admission.
• Triage and prioritize cases to meet turnaround time standards.
• Prepare and escalate cases to MDs for review when appropriate.
• Demonstrates effective communication methods and skills.
• Establishes relationships with providers for member services.
• Maintains accurate records of UR activities.
• Ensures compliance with state and federal regulations.
• Adapts to changes in policies and procedures.
• Responsible for outstanding customer service to all contacts.

Requirements

• Licensed RN or Associate degree in Nursing required.
• Minimum of two to three years varied clinical experience required.
• Managed care experience preferred.
• Ability to read and interpret documents and make clinical decisions.
• Excellent oral and written communication skills.
• Proficient in MS Office with basic computer skills.
• Excellent customer service skills.
• InterQual experience is required.

Benefits

• Innovative technology and services in healthcare administration.
• People-first approach in a vibrant work environment.
• Commitment to integrity and transparency.