Utilization Review Nurse-RN

Personify Health•Remote,

1d•$30 - $38•Onsite

About The Position

Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives.

Requirements

Current RN license in the United States or U.S. territory.
Associate’s degree or diploma (Nursing program) required.
1+ year clinical experience required.
Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards.
Ability to maintain regular, punctual attendance.
Ability to sit for 6-8 hours.
Constant use of computer keyboard and mouse; repetitive use of both hands.
Occasional to frequent twisting of neck; occasional bending of neck and at waist.
Must be able to remain in a stationary position 50% of the time.
The person in this job needs to occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities.
Constantly operates a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc.
Frequently positions self to maintain files in file cabinets.
Frequently moves boxes or equipment weighing up to 25 pounds.
Must communicate information and ideas so others understand. Must be able to exchange accurate information in these situations.
Must be able to observe details at close range.

Responsibilities

Provide professional assessment and review for the medical necessity of treatment requests and plans.
Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity; and post claim or post service reviews. Staff are expected to cross train, and provide cross coverage as needed.
Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO).
Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care.
Refer requests that fall outside of established guidelines to advance review or senior care consultants.
Process appeals for non-certification of services, complete non-certification letters when appropriate.
Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers.
Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together programs.
Complete documentation for all reviews in appropriate documentation software.
Utilize guidelines in appropriate hierarchy. Guidelines include MCG guidelines, internal medical policies, group specific policies, and NCCN.
Ability to meet productivity, quality, and turnaround times daily.
Ability to pass external audits to include URAC and NCQA.
Maintain HIPPA compliance per company’s policy and procedures.
Maintain confidentiality and minimum requirement rules.
Complete all required yearly training per company’s expected time limit.
Complete and pass all annual testing including IRRA at 90% or higher.