Utilization Review Nurse

Qualifications

• Bachelor’s degree in nursing or related field or an equivalent combination of work experience and education
• Current license as RN or LPN, current active single-state out-of-state nurse license, or current active multistate/compact nurse license
• Minimum 2 years of clinical nursing experience in a managed care, clinical, acute care, or community setting
• CCM or other case management certification preferred
• Demonstrated knowledge of payor contracts and able to provide clinical information to Physicians to ensure cost effective care and metrics standards
• Previous experience working with an EMR/EHR (Electronic Medical/Health Record) system
• Proficient Microsoft Office Suite skills
• Ability to convey empathy and compassion in emotionally charged situations
• Ability to effectively communicate in English (verbal and written)

Job Responsibilities

• Perform standard, retrospective, and/or concurrent reviews of authorization requests submitted by in-network and out-of-network providers
• Perform discharge planning assessment and coordination of subacute care services and benefit enhancements
• Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short- and long-term goals, treatment and provider options; coordinate and conduct utilization management activities
• Coverage of services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff to meet the complete medical socio-economic needs of clients; enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems
• Provide education to patients and providers
• Facilitate member access to community-based services
• Provide relevant data for Utilization Management Committee Meetings, attend and participate as required
• Identify related risk management quality concerns and report these scenarios to the appropriate resources

Pay

Pay Range: $73,915.89 - $110,874.35

This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy.