Utilization Review Nurse

Rising Medical Solutions • Chicago, IL

1d

About The Position

Rising Medical Solutions is hiring a Utilization Review Nurse to support its work reducing healthcare claim costs through bill review, case management, and utilization review. The role performs the utilization review process, evaluates clinical records and authorization requests, and uses evidence-based guidelines to make or route review decisions. It also requires accurate documentation, timely case tracking, communication with stakeholders, and responding to case-status inquiries. This is a full-time position working 40 hours per week, Monday through Friday.

Requirements

• Associate’s or bachelor’s degree in Nursing.
• Active, unencumbered RN license in one or more states.
• Three to five years of clinical practice experience, or two years of case management and/or utilization review experience.
• Ability to set priorities and work both autonomously and as a team member.
• Well-developed time-management, organization, and prioritization skills.
• Excellent analytical skills.
• Excellent oral and written communication skills.
• Ability to gather data, compile information, and prepare summary reports.
• Strong interpersonal and conflict-resolution skills.
• Experience in a fast-paced, multifaceted environment.
• Persistence and attention to detail.
• General understanding of CPT and ICD-9/ICD-10 codes and Medicare guidelines.
• Working knowledge of Microsoft Word, Excel, and Outlook.
• Ability to remain calm during stressful situations.
• Customer-service mindset.

Nice To Haves

• More than one state license.
• Experience with Workers’ Compensation, short-term or long-term disability, or liability claims.

Responsibilities

• Perform all aspects of the utilization review process.
• Review records and utilization review requests received by mail, email, fax, or phone.
• Use evidence-based guidelines to determine whether authorization can be granted or the file should be sent for peer or physician review.
• Write nurse summaries for all utilization review files.
• Document activity in Rising’s database and, when appropriate, client databases; send determination letters for completed reviews.
• Establish collaborative relationships with clients, patients, employers, providers, and attorneys.
• Track ongoing utilization review activity to meet appropriate turnaround times.
• Maintain organized files containing clinical documentation of interactions with all parties involved in each claim.
• Use clinical judgment, careful listening, critical thinking, and assessment skills.
• Respond to written and telephone inquiries about case status.
• Use a computer proficiently, including multiple software programs simultaneously.

Benefits

• Generous flexible time off.
• Comprehensive benefits package including health, dental, and vision insurance.
• Profit sharing.
• 401(k) matching.
• Career growth opportunities; the company often promotes from within.
• Professional Development Reimbursement Program (PDRP).
• Participation in the Elevate program, designed to recognize and reward employees for their work.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree