We are looking for a Utilization Review Nurse to join our team. REMOTE POSITION
Duties:
Analyzes and evaluates medical records and other health data to render medical necessity determinations using specific clinical criteria while adhering to regulatory turn-around times and provide review outcomes to members and providers in accordance with notification
standards. Implements utilization management processes and coordinate medical services with other departments, as well as local, state, and federal programs (Medicare, Medicaid, etc.). Reviews outpatient pre-authorization requests and/or retrospective requests through claims review and incoming requests through fax, electronic authorization platform, or telephone to ensure medical necessity for services requiring pre-authorization. Proactively and collaboratively interfaces with physicians, internal staff, members and members' families to assist in expediting appropriate discharge, obtain authorizations, and direct toward medically necessary care. Resolves member, family/caregiver assistance requests. Conducts concurrent reviews for inpatient stays (hospital, Skilled Nursing Facility, Rehab, Long Term Care Hospitals, etc.) and for Home Health agency services. Performs retrospective reviews as needed for services rendered without an authorization. Coordinates and acts as a resource to the facility Care Management staff in managing transition of care from the facility to alternative level of care. Coordinates with specialty vendors or providers for post-acute care needs.
Preferred Qualifications:
Current working knowledge of Medicare, Medicaid and Commercial insurance.
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Current working knowledge of utilization management and case management techniques.
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Working understanding of coding or utilization management criteria (i.e., InterQual, CMS manual).
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Ability to work independently, be self-motivated, have a positive attitude, and be flexible in a rapidly changing environment."
Education:
Bachelor's degree in Nursing (BSN). Education must be obtained from an accredited institution. Degree will be verified.
Current RN license in state of practice.