Utilization Review Registered Nurse

Hines & Associates Inc•Rockford, IL

just now•$57,244 - $62,180•Remote

About The Position

Hines & Associates is a nationwide, independent leader in personalized managed health care, focused on providing comprehensive services with program excellence and cost containment. With over three decades of experience, Hines is committed to conserving healthcare dollars while ensuring quality care through effective programs and personalized service. This role is a Monday through Friday position, 9:30 AM to 6:00 PM, offering a remote setting and a focus on work-life balance.

Requirements

Registered Nurse with valid, unrestricted, current nursing license in the state or territory of the United States where employed.
For mental health/substance abuse, licensed medical professional with an unrestricted license in the state or in a state that has licensure reciprocation with the state of the office location the employee is working in may perform first level reviews. Accepted licensure includes but is not limited to RN, LMSW, LMHC.
Must have Mental Health or Substance Abuse experience.
Successful completion of UR nurse orientation program.
Minimum of 3 years recent acute clinical practice required.
Customer service oriented.

Nice To Haves

5 years preferred acute clinical practice.
Managed care, disability or workers compensation experience helpful but not mandatory.

Responsibilities

Completes first level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review.
Demonstrates ability to assess a patient’s current medical status, including complications and untoward events, which may require additional intervention.
Provides certification of medical, disability and workers compensation cases.
Demonstrates a thorough understanding of criteria sets and their limitations including when a second level review is required.
Evaluates appropriateness of current plan of care.
Assesses aftercare needs, implements discharge planning and/or case management referral in a timely manner.
Maintains knowledge of current advances and trends in medical care.
Demonstrates knowledge of URAC guidelines, Hines policies and procedures, and standards of practice and their revisions.
Able to attain and maintain the minimal quality assurance performance standards.
Demonstrates assertiveness in completion of precertification and concurrent review within the guidelines of URAC, disability, workers compensation regulations, and state and federal requirements and according to the Hines policies and procedures.
Performs onsite evaluations as needed or requested.
Additional responsibilities as assigned.
Communicates with hospital staff, physicians, other providers and Hines customer contacts in a competent, calm, effective and professional manner.
Effectively communicates the need to refer to a higher-level review for questionable plans of treatment.
Provides written documentation concerning the clinical information obtained regarding the patient’s status, benefit and claim concerns, and validation of criteria.
Communicates knowledge of policies and procedures, URAC guidelines, disability and workers compensation regulations, state and federal requirements, and standards of practice.
Participates in self-evaluation by identifying areas of strength and limitations and offers and accepts constructive criticism.
Creative and assertive.
All First Level Reviewers are required to sign and honor a confidentiality statement at the time of hire and annually at the time of performance reviews.