Utilization Review Nurse

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

📋 Description

• Collaborate with the Medical Director to reduce care variance and facilitate timely discharges.

• Direct members to additional health plan resources that align with their care needs.

• Report to the Health Plan Manager of Utilization Management.

• Act as a vital and cooperative member of the health plan’s medical management team.

• Assist in developing and executing care management review processes, including Prior Authorization, Predetermination, Concurrent Reviews, and Retrospective Reviews.

• Conduct care management reviews based on established criteria, clinical guidelines, and policies.

• Ensure that interventions are collaborative and centered on enhancing member healthcare outcomes.

• Collaborate with Medical Directors to enhance the Peer-to-Peer Review process and support member and Provider Network services.

• Educate both internal and external stakeholders and partners.

• Work with the medical management team to pinpoint members who may benefit from coaching or case management interventions.

• Analyze collected data and collaborate with team members to enhance outcomes.

• Engage in lifelong learning and continuous process improvement within Utilization Management.

⛳️ Requirements

• Active Registered Nurse license issued by the state where services will be provided or a current multi-state Registered Nurse license via the enhanced Nurse Licensure Compact (eNLC).

• Minimum of three (3) years of clinical experience in healthcare.

• Proficient understanding of InterQual and/or Milliman Care Guidelines.

• Comprehensive knowledge of federal and state laws, NCQA, and industry regulations pertaining to disease management, utilization management, case management, and discharge planning.

• Exceptional written and verbal communication skills.

• Strong problem-solving abilities aimed at enhancing efficiencies and customer satisfaction.

• Keen attention to detail.

• Proficient in Microsoft Office.

• Availability for occasional weekend and holiday work may be necessary.

• Preferred: Bachelor's Degree in Nursing or Associate of Science in Nursing Degree (ASN); currently enrolled in a BSN program with completion within three (3) years of hire.

• Preferred: Experience in Medical Management for Medicare and/or Medicaid populations.

• Preferred: Background in Utilization Management.

🏝️ Benefits

• Full-time schedule with 40 hours scheduled each week.

• Exempt status.

• Remote work environment.

• Occasional weekend and holiday work may be required.