UM Nurse Reviewer

AllMed Healthcare Management•Portland, OR

13d•$34 - $43•Remote

About The Position

Join Our Team as a Utilization Management Reviewer! AllMed is looking for a detail-oriented and passionate Utilization Review Reviewer. This is a 100% remote position with a consistent schedule of Monday to Friday; 8:00 AM – 4:30 PM CT, giving you flexibility and work-life balance. In this role, you’ll play a critical part in delivering high-quality utilization review services. You’ll review and approve care based on evidence-based guidelines, ensuring medical necessity and appropriateness. Your work will uphold the highest standards of accuracy, integrity, and compliance with client agreements, regulatory requirements, and federal/state mandates. Responsibilities may include: Perform quality utilization review through the use of acquired knowledge and application of evidenced based guidelines for peer review reports, correspondences, addendums and/or supplemental reviews. Work directly with providers to identify level, intensity and duration of care. Document findings, continue to evaluate medical necessity for frequency, intensity and length of required care. Assure that the consistency and quality of reviews meets or exceeds industry standards. Work to ensure quality reviews are completed within the required client, federal and state or URAC mandated turnaround times. Maintain and apply knowledge of URAC and other state and federal regulatory requirements. Maintain accurate record of Utilization Reviews within the appropriate database. Direct Customer Service Representatives to ensure timely delivery of determination letters. Assist in resolution of client complaints and/or quality assurance issues as needed. Ensure all quality assurance standards and federal ERISA, URAC, and/or other state guidelines are adhered to at all times. Provide insight and direction to management on any compliance concerns regarding products, company policies and procedures and/or client specifications. Participate in company meetings, training activities and continuing education requirements. Perform all other duties as assigned. If you’re committed to excellence and passionate about improving healthcare outcomes, we’d love to have you on our team!

Requirements

High school diploma or equivalent required.
Must be a graduate of an accredited nursing program; bachelor’s degree preferred.
Minimum of three to five years of direct professional patient care required.
Experience in utilization management preferred.
Active unencumbered Registered Nurse, Licensed Practical Nurse or Licensed Vocational Nurse required.
Must hold and maintain an unencumbered Nursing license.
Inpatient Hospital/Facility review experience preferred.
Must have strong knowledge of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values.
Must be a qualified typist with a minimum of 40 W.P.M.
Must be able to operate a general computer, fax, copier, scanner, and telephone.
Must be knowledgeable of multiple software programs, including but not limited to Microsoft Suite.
Ability to follow instructions and respond to upper managements’ directions accurately.
Must demonstrate accuracy, thoroughness, and responsibility for quality of work, and ability to take initiative to identify improvements.
Look for ways to improve and promote quality and monitors own work to ensure quality is met.
Must be able to work independently, prioritize work activities and use time efficiently.
Must be able to maintain confidentiality.
Must be able to demonstrate and promote a positive team -oriented environment.
Must be able to stay focused and concentrate with frequent interruptions and be able to work well under pressure and or stressful conditions.
Must possess the ability to manage change, delays, or unexpected events appropriately.
Ability to follow all company policies and procedures in effect at time of hire and as they may change or be added from time to time.

Nice To Haves

Experience in utilization management preferred.
Inpatient Hospital/Facility review experience preferred.

Responsibilities

Perform quality utilization review through the use of acquired knowledge and application of evidenced based guidelines for peer review reports, correspondences, addendums and/or supplemental reviews.
Work directly with providers to identify level, intensity and duration of care.
Document findings, continue to evaluate medical necessity for frequency, intensity and length of required care.
Assure that the consistency and quality of reviews meets or exceeds industry standards.
Work to ensure quality reviews are completed within the required client, federal and state or URAC mandated turnaround times.
Maintain and apply knowledge of URAC and other state and federal regulatory requirements.
Maintain accurate record of Utilization Reviews within the appropriate database.
Direct Customer Service Representatives to ensure timely delivery of determination letters.
Assist in resolution of client complaints and/or quality assurance issues as needed.
Ensure all quality assurance standards and federal ERISA, URAC, and/or other state guidelines are adhered to at all times.
Provide insight and direction to management on any compliance concerns regarding products, company policies and procedures and/or client specifications.
Participate in company meetings, training activities and continuing education requirements.
Perform all other duties as assigned.