Utilization Review Nurse - Remote

TruHealth•Franklin, TN

9d•Remote

About The Position

The Utilization Review Nurse assesses the medical necessity and quality of healthcare services through pre-service, concurrent, and retrospective utilization management reviews. The role provides clinical support to the Clinical Services Department and Medical Director to help ensure members receive appropriate medical services in compliance with medical and regulatory guidelines. The nurse evaluates the medical necessity, quality, level, and appropriateness of services; identifies suitable placement settings that provide the lowest level of restriction and greatest autonomy; gathers clinical information from requesting providers; and applies clinical review criteria to cases. The role certifies cases that meet review criteria, consults with a physician when criteria are not met, and refers cases to other professionals when indicated. The nurse also follows applicable accreditation, contractual, and regulatory timeframes and promptly raises potential risk management issues.

Requirements

At least 1 year of utilization management experience with a health plan or hospital-based UM department, including use of InterQual or MCG.
Current, active, and unrestricted Registered Nurse (RN) license.
Broad knowledge of Medicare regulations and guidance.
Training in clinical certification, utilization management, and URAC and NCQA principles, policies, and procedures.
Excellent customer service experience.
Strong knowledge of medical terminology and CPT, ICD-10, and HCPCS codes.
Strong oral and written communication skills, including active listening.
Proficiency navigating multiple computer applications.
Critical thinking, problem-solving, and decision-making skills, including the ability to make decisions under pressure.
Ability to work independently and as part of a team, manage multiple priorities, and exercise independent discretion.
Ability to work congenially with a wide variety of people and provide positive, engaging customer service.
Self-motivation and successful completion of required training.
Ability to maintain professionalism and confidentiality and support a warm, optimistic atmosphere focused on patients' personal and healthcare needs.

Nice To Haves

Clinical experience is preferred.
Current Certified Case Manager (CCM) credential.

Responsibilities

Assess the medical necessity, quality of care, level of care, and appropriateness of healthcare services for plan members.
Identify placement settings that offer the lowest level of restriction and greatest level of autonomy based on medical necessity.
Contact requesting providers, including specialty physicians, ancillary providers, and institutions, to gather necessary clinical data.
Apply clinical review criteria, guidelines, and screens to determine medical necessity against the clinical data provided.
Certify cases that meet clinical review criteria, guidelines, and/or screens.
Consult with a physician when reviews do not meet clinical review criteria, guidelines, and screens.
Refer cases to internal professionals, including case management and medical consultation, when indicated.
Complete utilization management reviews within accreditation, contractual, and regulatory timeframes.
Ensure the Director of Medical Management or designee is promptly informed of potential risk management issues.
Maintain privacy and confidentiality of records and information relating to residents, employees, and facilities.
Develop and maintain collaborative relationships with providers and educate them on levels of care.
Perform other duties as assigned.