Utilization Review Nurse

Summary

Join The Oncology Institute of Hope and Innovation (TOI) as a Utilization Management Nurse (UM RN) and ensure timely, high-quality, and cost-effective cancer care. Reporting to the Chief Clinical Officer, you will review patient cases, conduct pre-authorization reviews, and make utilization management decisions based on evidence-based guidelines. Collaborate with various teams to facilitate care and maintain accurate documentation. Adhere to policies and procedures, participate in quality improvement initiatives, and ensure efficient workflows. This fully remote position requires strong communication, problem-solving, and analytical skills, along with three years of utilization management experience and an active nursing license.

Requirements

• Strong verbal and written communication skills
• Ability to work independently, initiate, and successfully complete tasks
• Problem-solving aptitude and the ability to navigate challenging situations with sensitivity and professionalism
• Excellent analytical and critical thinking skills with attention to detail for decision-making and problem-solving
• Must be actively licensed, in good standing, by the appropriate regulatory body in the applicable state
• Mastery of computer skills, including Word, Excel, Power Point and applicable electronic medical software programs
• Maintain regular attendance
• Ability to effectively present information and respond to questions
• Three (3) years of experience in utilization management

Responsibilities

• Review cases for completeness of supporting documentation
• Conduct pre-authorization review of services to ensure compliance with medical policy and contracts
• With the UM Medical Directors, utilize evidence-based clinical guidelines to make utilization management decisions
• Meet delivery timelines in notifying patients and providers of authorization decisions
• Collaborate with nursing, eligibility, and authorization teams to facilitate continuity of care and optimal patient outcomes
• Maintain accurate documentation of utilization and case management activities and report on those regularly
• Adhere to practice policies and procedures, including compliance with HIPAA privacy and security requirements and all state, federal and plan regulatory mandates
• Participate in quality improvement initiatives to enhance processes and service delivery
• Participate in process improvement/cost of health care initiatives
• Ensure workflow procedures and guidelines are clearly documented and communicated
• Interpret or initiate changes in guidelines/policies/procedures
• Collaborate across functionally to improve member outcomes
• Participate in Regulatory and Internal Audits

Benefits

Fully remote position