PRN Utilization Review Nurse Reviewer

About the role

The Utilization Management Nurse Reviewer plays a crucial role in healthcare systems by ensuring that medical services are used efficiently and appropriately. They review medical records, treatment plans, and patient information to determine the necessity and appropriateness of medical procedures, tests, and treatments. Utilization Management Nurse Reviewers collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and maintain quality care.

Responsibilities

• Conduct assessments of medical services to validate their appropriateness using established criteria and guidelines, ensuring the medical necessity of treatments (e.g., CMS, Milliman Care Guidelines, InterQual, or health plan specific guidelines/criteria)
• Examine and evaluate patient records to verify the quality of patient care and the necessity of provided services
• Offer clinical expertise and serve as a clinical reference for non-clinical staff members
• Input and manage essential clinical details within various medical management platforms
• Keep up-to-date with regulatory prerequisites (such as URAC) and state standards for utilization review
• Apply clinical reasoning to determine the suitable evidence-based guidelines
• Foster efficient and high-quality patient care by effectively communicating with management teams, physicians, and the Medical Director

Requirements

• Proficient in both written and spoken communication
• Capable of maintaining professional communication with physicians and clients
• Skilled at handling multiple tasks and adjusting swiftly in a dynamic office setting
• Pays close attention to details and possesses a keen organizational sense
• Adept at resolving intricate and multifaceted problems
• Experienced with Microsoft tools such as Word, Excel, PowerPoint, and Outlook
• Education/Credentials: Licensed Practical/Vocational Nurse with an active and unrestricted license to practice
• Job Relevant Experience: 2 years minimum clinical nursing experience, one year of previous experience in Utilization Management is required
• Job Related Skills/Competencies: Strong abilities in both spoken and written communication, along with effective interpersonal skills. Proficient understanding of computer operations, particularly the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows. Capability to acquire new skills and competencies to address the evolving requirements of systems, software, and hardware

Additional Duties

• May provide oversight to the work of the team members
• Continuously improves processes that help to facilitate better turnaround time, peer to peer success rates and lessens returned reports by clients for clarification purposes, ultimately resulting in higher client satisfaction
• Responsible for the final approval on cases for release to the client
• Acts as a liaison and coordinates quality issue reports along with all new reviewer reports with the VP of Clinical Operations

Education/Credentials

Licensed Practical/Vocational Nurse with an active and unrestricted license to practice.

Benefits

• Comprehensive benefits package including health insurance, retirement plans, and performance bonuses
• Voluntary life insurance options for you, your spouse, and your children
• Hospital indemnity, critical illness, accident indemnity, and pet insurance plans
• Basic life insurance, short-term disability, and long-term disability coverage at no cost
• 401k plan with a company match
• Apple equipment and a media stipend for remote workspace

About Dane Street

A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers' Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.