Utilization Review Nurse (FT)
About The Position
The Utilization Review Nurse is responsible for reviewing requests for services against various organizational review guidelines and criteria in order to efficiently direct patients to the appropriate medical professionals, ensuring medical necessity of treatment as well as appropriate and efficient use of hospital resources under the auspices of a patient’s health plan benefits and coverage. This individual will work to identify the most appropriate course of treatment that will result in cost-effective and high-quality medical care for the patient, according to the patient’s insurance plan. Additionally, the incumbent will work closely with payers to ensure that the organization is fully compensated for any and all services delivered and will gain authorizations for any pending services and procedures not yet performed. This may also include reviewing and appealing claims denied by insurance carriers.
Requirements
- At least 3 years’ experience as a licensed healthcare professional in a medical setting
- valid licensure as a healthcare professional or certification as a case manager and or certification in utilization management
Nice To Haves
- Bachelor’s degree in nursing or health related field preferred
- Previous experience with utilization review and/or case management preferred
Responsibilities
- Reviewing requests for services against various organizational review guidelines and criteria
- Efficiently direct patients to the appropriate medical professionals
- Ensuring medical necessity of treatment
- Ensuring appropriate and efficient use of hospital resources under the auspices of a patient’s health plan benefits and coverage
- Identify the most appropriate course of treatment that will result in cost-effective and high-quality medical care for the patient, according to the patient’s insurance plan
- Work closely with payers to ensure that the organization is fully compensated for any and all services delivered
- Gain authorizations for any pending services and procedures not yet performed
- Reviewing and appealing claims denied by insurance carriers
Benefits
- Competitive Pay Rates
- Company Swag
- Comprehensive Benefit Package
- Tuition Reimbursement
- Matching Retirement Plan
- Sign on Bonus (select positions)
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
