Utilization Review Nurse

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

📋 Description

• Execute utilization and concurrent assessments of inpatient cases utilizing Milliman, Aetna, and BCBS criteria.

• Perform medical necessity evaluations for services that necessitate prior authorization, applying criteria specific to utilization.

• Gather and assess clinical information essential for reviewing requested services.

• Engage in discussions regarding cases and determinations with healthcare professionals and physician reviewers.

• Recognize cases that need intervention and collaborate with Case Managers when necessary.

• Maintain precise and suitable documentation to ensure compliance with audit requirements.

• Contribute to team meetings, educational sessions, and associated activities.

• Analyze medical claims and pre-determinations for medical necessity and suitability.

• Spot opportunities for process enhancement and improve communication across departments.

• Consult with Physician Reviewers for complex or difficult cases.

⛳️ Requirements

• Valid and unrestricted RN license (State license mandatory).

• At least 3 years of clinical nursing experience.

• A minimum of 1 year of experience in Utilization Management (UM) or Utilization Review (UR).

• Exceptional analytical, critical thinking, and problem-solving abilities.

• Proficient in Microsoft Office Suite (Excel, Word, Outlook) and knowledgeable about utilization management systems.

• Outstanding verbal and written communication skills, capable of effectively interacting with both internal and external stakeholders.

• Strong organizational and time management skills, with the capacity to manage multiple priorities independently.

🏝️ Benefits

• Exceptional medical, dental, and vision insurance*

• Biannual employer HSA contributions covering 50% of the HDHP plan’s annual deductible!

• Company-sponsored Basic Life and AD&D coverage

• Company-funded Short-Term and Long-Term Disability**

• Flexible Spending Accounts*

• 401(k) Retirement Plan with up to a 6% employer match** (100% fully vested after 3 years)

• More than 10 paid holidays

• Half-day Summer Fridays

• Generous paid vacation and sick time

• Annual paid Volunteer Day

• Annual Tuition reimbursement

• Annual Health and Wellness reimbursement

• Numerous enjoyable company events