Utilization Review Nurse

Rising Medical Solutions • Chicago, IL

2d

About The Position

Rising Medical Solutions is hiring a full-time Utilization Review Nurse to support its healthcare cost-containment work. The role performs the utilization review process, evaluating clinical records and requests using evidence-based guidelines and determining whether to authorize services or refer a file for peer or physician review. The nurse documents reviews, prepares summaries and determination letters, tracks activity to meet turnaround times, and communicates with clients, patients, employers, providers, and attorneys. This position is 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.
• 3 to 5 years of clinical practice experience, or 2 years of case management and/or utilization review experience.
• Experience with workers' compensation, short-term or long-term disability, or liability claims.
• Ability to set priorities and work autonomously as well as collaboratively.
• 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.
• Demonstrated 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 RN license.

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 given or whether a file must 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 each completed review.
• Establish collaborative relationships with clients, patients, employers, providers, and attorneys.
• Track the status of 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.

What This Job Offers

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