Utilization Review Nurse

This is a fully remote position, open to applicants in Arizona, +16 more states.

📋 Description

• Conduct regular case reviews and examine medical records.

• Communicate with healthcare providers regarding treatment as necessary.

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

• Report to the Supervisor of Utilization Review.

• Perform medical necessity assessments and level of care evaluations for requested services, utilizing clinical judgment along with Oscar Clinical Guidelines and Milliman Care Guidelines.

• Gather essential information (via phone and fax) to evaluate a member's clinical condition and apply the relevant evidence-based guidelines.

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

• Refer members for additional care engagement when necessary.

• Ensure compliance with all applicable laws and regulations.

• Execute other duties as assigned.

⛳️ Requirements

• Active, unrestricted RN licensure from the United States in [state] OR a valid compact multistate unrestricted RN license as stipulated by the Nurse Licensure Compact (NLC).

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

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

• A minimum of 1 year of utilization review experience in a managed care environment.

• Significant experience using MCG (Milliman Care Guidelines).

• At least 1 year of clinical experience, including a minimum of 1 year of clinical practice in an acute care setting, such as an emergency room or hospital.

🏝️ Benefits

• Employee benefits.

• Monthly vacation accrual at a rate of 15 days per year.