Utilization Review Nurse Reviewer - LPN

Summary

Join our team as a Utilization Management Nurse Reviewer (PRN) and play a crucial role in ensuring efficient and appropriate use of healthcare services. You will review medical records, collaborate with healthcare providers, and make informed decisions regarding patient care. This PRN position offers flexible scheduling, but requires working at least one weekend per month, one major holiday, and one minor holiday per year. A minimum number of shifts per month is mandated to maintain skills and familiarity with processes. The role demands strong clinical knowledge, critical thinking, and communication skills. We offer a comprehensive benefits package including health insurance, retirement plans, and performance bonuses.

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
• 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
• 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

Preferred Qualifications

• Supply and support their own internet services
• Maintaining an uninterrupted internet connection is a requirement of all work from home position

Benefits

• Health insurance
• Retirement plans
• Performance bonuses
• 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
• 401k plan with a company match
• Apple equipment and a media stipend for remote workspace