Utilization Review Nurse

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

📋 Description

• Perform evaluations of medical services to confirm their appropriateness using established criteria and guidelines, ensuring that treatments are medically necessary (e.g., CMS, Milliman Care Guidelines, InterQual, or health plan specific guidelines/criteria).

• Review and assess patient records to validate the quality of care provided and the necessity of services rendered.

• Provide clinical expertise and act as a clinical resource for non-clinical staff members.

• Enter and manage critical clinical information within various medical management systems.

• Stay informed about regulatory requirements (such as URAC) and state standards for utilization review.

• Utilize clinical judgment to apply the appropriate evidence-based guidelines.

• Promote effective and high-quality patient care by maintaining communication with management teams, physicians, and the Medical Director.

⛳️ Requirements

• Excellent written and verbal communication skills.

• Ability to maintain professional interactions with physicians and clients.

• Proficient in managing multiple tasks and adapting quickly in a fast-paced office environment.

• Strong organizational skills with a keen eye for detail.

• Capable of resolving complex and challenging issues.

• Familiarity with Microsoft tools such as Word, Excel, PowerPoint, and Outlook.

• Background in medical or clinical practice through education, training, or professional experience.

• Must possess an unrestricted LVN/RN license from an accredited vocational nursing program (for LVNs) or a nursing degree from an accredited institution (for RNs).

🏝️ Benefits

• Medical, dental, and vision insurance for you and your family.

• Voluntary life insurance options available for you, your spouse, and your children.

• Additional voluntary benefits including hospital indemnity, critical illness coverage, accident indemnity, and pet insurance plans.

• Basic life insurance, short-term disability, and long-term disability coverage offered at no cost.

• Generous paid time off policy to ensure you have the opportunity to relax and rejuvenate.

• 401k plan with company matching to assist you in planning for your future.

• Apple equipment and a media stipend provided for remote work.