Utilization Management Nurse Reviewer

Summary

Join our team as a Utilization Management Nurse Reviewer and ensure efficient and appropriate use of medical services. You will review medical records and treatment plans, collaborate with healthcare providers and insurance companies, and make informed decisions regarding patient care pathways. Responsibilities include assessing medical necessity, coordinating care, conducting utilization reviews, and providing recommendations for care plans. This role requires strong clinical knowledge, critical thinking skills, and excellent communication abilities. Shifts are available in the evenings and on weekends. We offer a comprehensive benefits package.

Requirements

• Proficient in both written and spoken communication
• Capable of maintaining professional communication with physicians and clients
• Skilled at handling multiple tasks and adjusting swiftly in a dynamic office setting
• Possesses a keen organizational sense and pays close attention to details
• Adept at resolving intricate and multifaceted problems
• Experienced with Microsoft tools such as Word, Excel, PowerPoint, and Outlook
• Background in medical or clinical practice through education, training, or professional engagement
• Holds an unrestricted LVN/RN license from an accredited vocational nursing program (for LVNs) or a nursing degree from an accredited college (for RNs)
• Licensed Practical/Vocational Nurse with an active and unrestricted license to practice
• Licensed RN with an active and unrestricted license to practice
• 2 yrs minimum clinical nursing experience is required
• One year of previous experience in Utilization Management is required
• Demonstrate strong abilities in both spoken and written communication, along with effective interpersonal skills
• Possess a proficient understanding of computer operations, particularly the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows
• Show the capability to acquire new skills and competencies to address the evolving requirements of systems, software, and hardware

Responsibilities

• Conduct assessments of medical services to validate their appropriateness using established criteria and guidelines, ensuring the medical necessity of treatments (e.g., CMS, Milliman Care Guidelines, InterQual, or health plan specific guidelines/criteria)
• Examine and evaluate patient records to verify the quality of patient care and the necessity of provided services
• Offer clinical expertise and serve as a clinical reference for non-clinical staff members
• Input and manage essential clinical details within various medical management platforms
• Keep up-to-date with regulatory prerequisites (such as URAC) and state standards for utilization review
• Apply clinical reasoning to determine the suitable evidence-based guidelines
• Foster efficient and high-quality patient care by effectively communicating with management teams, physicians, and the Medical Director

Preferred Qualifications

• May provide oversight to the work of the team members
• Continuously improves processes that help to facilitate better turnaround time, peer to peer success rates and lessens returned reports by clients for clarification purposes, ultimately resulting in higher client satisfaction
• Responsible for the final approval on cases for release to the client
• Will act as a liaison and coordinate quality issue reports along with all new reviewer reports with the VP of Clinical Operations

Benefits

• Medical, dental, and vision coverage for you and your family
• Voluntary life insurance options for you, your spouse, and your children
• Other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans
• Basic life insurance, short-term disability, and long-term disability coverage at no cost
• Paid time off policy
• 401k plan with a company match
• Apple equipment and a media stipend are provided for remote workspace