Utilization Review Nurse

About This Role

The Utilization Review Nurse assesses the medical necessity and quality of healthcare services by conducting pre-service, concurrent, and retrospective utilization management reviews. This role provides clinical support to the Clinical Services Department and Medical Director to ensure that members receive appropriate medical services in compliance with medical and regulatory guidelines.

Responsibilities

• Assess the medical necessity, quality of care, level of care, and appropriateness of healthcare services for plan members
• Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for members based on medical necessity
• Conduct outreach to requesting providers, including specialty physicians, ancillary providers, and institutions to gather necessary clinical data
• Apply clinical review criteria, guidelines, and screens in determining the medical necessity of healthcare services against the clinical data provided
• Certify cases that meet clinical review criteria, guidelines, and/or screens
• Consult with physicians when reviews do not meet clinical review criteria, guidelines, and screens
• Refer cases to other professionals internally, including case management and medical consultation when indicated
• Adhere to accreditation, contractual, and regulatory timeframes in performing all utilization management review processes
• Ensure that the Director of Medical Management or designee is made aware of any potential risk management issues in a timely manner
• Perform other duties as assigned

Requirements

• At least 1 year of experience in utilization management with a health plan or hospital-based UM department using Interqual or MCG
• Prefer clinical experience
• Broad knowledge of Medicare regulations and guidance
• Trained in clinical certification, utilization management, URAC, and NCQA principles, policies, and procedures
• Excellent customer service experience
• Strong knowledge of medical terminology and CPT, ICD-10, and HCPCS codes
• Proven ability to problem-solve and make solid decisions
• Current, active, and unrestricted Registered Nurse (RN) license

Nice to have:

• Current Certified Case Manager (CCM) credential

Benefits

• Affordable Medical/Dental/Vision insurance options
• Generous paid time-off program and paid holidays for full-time staff
• TeleDoc 24/7/365 access to doctors
• Optional short- and long-term disability plans
• Employee Assistance Plan (EAP)
• 401K retirement accounts with company match