Utilization Review Nurse - Infusion

About This Role

This nursing role focuses on evaluating medical records and clinical data to ensure healthcare services are medically necessary and cost-effective, aligning with regulatory and payer requirements. The position involves reviewing biologic medication treatments and collaborating with various healthcare stakeholders to gather documentation. It suits a Registered Nurse with clinical experience who can apply standardized criteria and contribute to quality improvement.

Responsibilities

• Conduct clinical reviews of biologic medication treatments to determine medical necessity
• Apply standardized criteria and payer-specific guidelines
• Collaborate with patients, providers, and other healthcare facilities to gather required clinical documentation
• Prepare and document clinical reviews and recommendations in accordance with organizational policy and regulatory standards
• Participate in quality improvement initiatives and audits
• Identify trends in utilization and report findings to leadership
• Answer phone calls and return voicemails in a timely manner
• Check and resolve assigned tasks in Electronic Health Record
• Adhere to compliance of OAC policies and standard operating procedures
• Set the standard for the team with excellent patient care
• Maintain open and positive lines of communication, and functionality
• Understand and adhere to HIPAA laws and regulations in compliance and patient confidentiality

Requirements

• Active and unrestricted Registered Nurse license in Oklahoma
• Minimum of 3 years of clinical experience (e.g., Med-Surg, ICU, Case Management, Utilization Review)
• Knowledge of medical terminology, anatomy and physiology
• Familiarity with health care systems, regulations, policies and functions
• Understanding of documentation standards
• Knowledge of equipment, supplies and materials needed for medical treatment
• Understanding of basic laboratory procedures including preparation and screening
• Knowledge of disease process and treatment options
• Excellent customer service skills
• Attention to detail
• Strong written and verbal communication skills
• Excellent analytical and decision-making skills
• Proficiency with electronic medical record (EMR) systems and Microsoft Office Suite
• Ability to work effectively in a fast-paced environment
• Physical ability to sit, perform data entry and view computer screen for long periods at a time
• Occasional exposure to communicable diseases and biohazards
• Daily standing, walking, bending, and maneuvering