Utilization Management Nurse, RN

This is a fully remote position, open to applicants in Oklahoma.

📋 Description

• Provide administrative and clinical assistance to the hospital and treatment teams during patient evaluations.

• Facilitate patient placement across various levels of care and ensure the receipt of required services.

• Communicate reimbursement concerns to healthcare providers.

• Engage in treatment teams, the Patient Care Committee, and the Utilization Review Staff Committee.

• Collect, prepare, and provide clinical/treatment information needed for authorization within designated review timeframes.

• Offer information on eligibility, benefits, and level-of-care criteria.

• Assist in discharge planning as necessary.

• Identify and report triggers for quality improvement.

• Review patient eligibility and benefits to confirm proper level-of-care utilization.

• Investigate and prepare insurance appeals pertaining to medical necessity or other treatment concerns.

• Participate in the enhancement of quality-of-care and utilization management processes.

• Aid in the establishment of process-improvement goals for the Utilization Review Staff Committee.

• Provide educational support to staff in alignment with utilization review objectives.

⛳️ Requirements

• Previous experience in Utilization Management is preferred.

• Completion of the basic professional curriculum from a nursing school accredited and verified by a state nursing board, possessing or eligible for a diploma or degree, or a Master’s degree in Nursing.

• A valid multi-state or State of Oklahoma Registered Nurse License.

• At least 2 years of relevant experience in an acute care environment.

• Capability to effectively and efficiently organize and prioritize work.

• Strong interpersonal, written, and verbal communication skills.

• Ability to analyze data for the discovery of facts or the development of knowledge, concepts, or interpretations.

• Detail-oriented approach to examining numerical data.

• Skill in synthesizing clinical case data into concise summaries.

• Proficient in Microsoft Word, Excel, and Access.

• Ability to interact directly with patients, customers, healthcare professionals, and staff.

• Capability to collaborate with individuals at the Director level or higher.

🏝️ Benefits

• Full-time work schedule.

• Day shift hours.

• Working hours: Saturday, Sunday, and Monday, from 6:45 am to 7:15 pm.