Utilization Review Nurse – Infusion

About the role

The Medical Necessity Review Nurse is responsible for evaluating medical records and clinical data to determine the appropriateness, medical necessity, and efficiency of health care services, according to established criteria and guidelines. This role helps ensure that patients receive medically necessary care while also supporting cost-effective treatment planning in line with regulatory and payer requirements.

Responsibilities

• Conduct clinical reviews of biologic medication treatments to determine medical necessity.
• Apply standardized criteria payer-specific guidelines.
• Collaborate with patients, providers and other healthcare facilities to gather required clinical documentation.
• Prepare and document clinical reviews and recommendations in accordance with organizational policy and regulatory standards.
• Participate in quality improvement initiatives and audits.
• Identify trends in utilization and report findings to leadership.
• Answer phone calls and return voicemails in a timely manner.
• Check and resolve assigned tasks in Electronic Health Record.
• Adhere to compliance of OAC policies and standard operating procedures.
• Set the standard for the team with excellent patient care.
• Maintain open and positive lines of communication, and functionality.
• Understand and adhere to HIPAA laws and regulations in compliance and patient confidentiality.

Requirements

• Knowledge of medical terminology, anatomy and physiology.
• Familiarity with health care systems, regulations, policies and functions.
• Understanding of documentation standards.
• Knowledge of equipment, supplies and materials needed for medical treatment.
• Understanding of basic laboratory procedures including preparation and screening.
• Knowledge of disease process and treatment options.
• Ability to work effectively in a fast-paced environment.
• Physical ability to sit, perform data entry and view computer screen for long periods at a time.
• Occasional exposure to communicable diseases and biohazards.
• Daily standing, walking, bending, and maneuvering.
• May require lifting up to 50 pounds or more to transfer and/or turn patient with and without assistive devices.
• Travel may be required.
• Proficiency with standard office equipment including computers, printers, faxes, copiers, postage machine, etc.

Qualifications

• Active and unrestricted Registered Nurse license in Oklahoma.
• Minimum of 3 years of clinical experience (e.g., Med-Surg, ICU, Case Management, Utilization Review).

Skills

• Excellent customer service skills.
• Attention to detail.
• Strong written and verbal communication skills.
• Excellent analytical and decision-making skills.
• Proficiency with electronic medical record (EMR) systems and Microsoft Office Suite.

Schedule

Normal work hours are 8:00 a.m. to 5:00 p.m., Monday through Thursday and 8:00 a.m. to 1:00 p.m. on Fridays. Hours may vary depending upon the needs of the position, department, and clinic.