Utilization Review Nurse

Healthaxis • Tampa, FL

267d • Remote

About The Position

The Utilization Review Nurse is responsible for the medical necessity review of outpatient services that require prior authorization, and/or management of concurrent inpatient admissions. The medical necessity review process includes assessment and interpretation of plan specific benefits, medical criteria, and clinical documentation.

Requirements

• Licensed RN or LPN required.
• Minimum of two to three years varied clinical experience required.
• Managed care experience preferred.
• An equivalent combination of education, training, and experience.
• Ability to read and interpret documents and calculate figures and amounts.
• Excellent oral and written communication skills including good grammar, voice and diction.
• Proficient in MS Office with basic computer and keyboarding skills.
• Excellent customer service skills (friendly, courteous and helpful).

Nice To Haves

• InterQual experience helpful.

Responsibilities

• Performs prospective, concurrent, and retrospective inpatient and/or outpatient utilization reviews (UR) using evidence-based guidelines, policies and nationally recognized clinical criteria, and internal policies and procedures.
• Evaluates severity of illness and intensity of service of member's needs at time of inpatient admission utilizing approved criteria.
• Triage and prioritize cases and other assigned duties to meet CMS turnaround time standards.
• Prepare and escalate cases to MDs for review when appropriate.
• Demonstrates effective communication methods and skills, using lines of authority appropriately.
• Establishes a relationship with providers to determine/provide needed services to member.
• Maintains accurate record of UR activities.
• Regular attendance is required as employee works as part of a team & requires interaction with medical staff and clients.
• Adheres to quality standards and confidentiality policies and procedures.
• Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.
• Adapts to changes in policies, procedures, new techniques, and additional responsibilities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Computing Infrastructure Providers, Data Processing, Web Hosting, and Related Services
• Education Level: Bachelor's degree