Utilization Review RN, PRN

About the role

As a Utilization Review RN, you will review cases to determine medical suitability for insured patients. Your expertise will be used to conduct meticulous clinical reviews using established criteria. You will play a key role in supporting the healthcare team by optimizing resources and implementing care plans. Communication with health plan departments is important to ensure services meet medical necessity standards, including prospective, concurrent, and retrospective reviews.

Responsibilities

• Review all cases using medical guidelines to evaluate services.
• Understand patient needs and resolve complex matters when necessary.
• Confirm admission status is correct and collaborate with Utilization Review coordinators when needed.
• Communicate with insurance companies and doctors about patients to ensure needed paperwork is completed.
• Report insurance company issues to leadership and identify and communicate quality assurance or risk management issues promptly when they arise.
• Evaluate, develop, and implement protocols, policies, and procedures to improve processes.

Qualifications

• Associate degree.
• Prior experience of at least three years in the nursing field.
• Must have a valid nursing registration (RN).

Skills

• Comprehensive understanding of diverse healthcare techniques, practices, and industry-related language.
• Proficiency in customer engagement, ensuring their concerns are heard and promptly addressed.
• Thorough understanding of discharge planning, care coordination, utilization assessment and care levels.
• Knowledge of local and national regulations, including those from the Department of Insurance, Department of Labor, Centers for Medicare and Medicaid Services, Health and Human Services Commission, and National Committee for Quality Assurance.
• Exceptional communication skills, including articulating thoughts clearly in speech and writing.
• Personable, with the ability to interact effectively with a diverse range of stakeholders.
• Problem-solving capability, equipped with critical thinking skills.
• Ability to juggle multiple tasks and work under time pressures.

Benefits

• Immediate eligibility for health and welfare benefits.
• 401(k) savings plan with dollar-for-dollar match up to 5%.
• Tuition Reimbursement.
• PTO accrual beginning Day 1.