This is a fully remote position, open to applicants in Arizona, +15 more states.

📋 Description

• Conduct regular case assessments.

• Review medical records and communicate with care providers regarding treatment as necessary.

• Provide recommendations on the appropriateness of care for identified diagnoses based on research findings.

• Report to the Supervisor of Utilization Review.

• Complete reviews of medical necessity and levels of care using clinical judgment, Oscar Clinical Guidelines, and Milliman Care Guidelines.

• Gather information via telephone and fax to evaluate members' clinical conditions and apply evidence-based guidelines.

• Adhere to required decision-making service level agreements (SLAs).

• Refer members for additional care engagement when necessary.

• Ensure compliance with relevant laws and regulations.

• Perform other assigned duties.

⛳️ Requirements

• Active, unrestricted RN license from the United States in [state], OR an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).

• Associate Degree in Nursing or graduation from an accredited School of Nursing, or successful completion of a Nursing Diploma Program in an accredited School of Nursing.

• Capability to obtain additional state licenses to fulfill business requirements.

• At least 1 year of experience in utilization review within a managed care environment.

• Significant experience using MCG (Milliman Care Guidelines) or InterQual.

• Minimum of 1 year of clinical experience, including at least 1 year in an acute care setting such as an ER or hospital.

• Weekend availability is required; must be able to work at least one weekend day each week.

• BSN is an advantageous qualification.

• Prior experience conducting concurrent or inpatient reviews for a managed care plan is a plus.