Utilization Review Nurse
About The Position
You will perform frequent case reviews, check medical records and speak with care providers regarding treatment as needed. You will make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions. You will report into the Supervisor, Utilization Review. Work Location: This is a remote position, open to candidates who reside in: Texas, Georgia, Arizona, and Florida. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events.
Requirements
- Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
- Associate Degree or Bachelors Degree - Nursing or Graduate of Accredited School of Nursing
- MCG or InterQual tooling experience
- Ability to obtain additional state licenses to meet business needs
- 1+ year of utilization review experience in a managed care setting
- 1+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital)
Nice To Haves
- BSN
- Previous experience conducting concurrent or inpatient reviews for a managed care plan
Responsibilities
- Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines
- Obtain the information necessary (via telephone and fax) to assess a member's clinical condition, and apply the appropriate evidence-based guidelines
- Meet required decision-making SLAs
- Refer members for further care engagement when needed
- Compliance with all applicable laws and regulations
- Other duties as assigned
Benefits
- employee benefits
- monthly vacation accrual at a rate of 15 days per year
- medical, dental, and vision benefits
- 11 paid holidays
- paid sick time
- paid parental leave
- 401(k) plan participation
- life and disability insurance
- paid wellness time and reimbursements
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
1,001-5,000 employees
