Utilization Review Nurse

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

📋 Description

• Assess treatment plan requests and gather as well as evaluate relevant medical records.

• Resolve ambiguous treatment plan requests by reaching out to the offices of the requesting providers.

• Apply evidence-based criteria and jurisdictional guidelines to make determinations for utilization review.

• Seek Physician Advisor services for requests that do not align with evidence-based criteria.

• Negotiate treatment plan requests with requesting providers when medically appropriate and within jurisdictional limits.

• Forward certified treatment plan requests to preferred vendors as necessary.

• Record outcomes of utilization review in the designated utilization review software.

• Collaborate with claim examiners to share clinical information and address any issues that arise.

• Sustain a monthly internal utilization review audit score of 90% or above.

• Achieve productivity targets set by the supervisor.

⛳️ Requirements

• An active, unrestricted RN license in a U.S. state or territory is mandatory.

• An associate degree from an accredited institution is required.

• Certification in utilization review is preferred.

• A minimum of four (4) years of relevant experience or an equivalent combination of education and experience is necessary.

• At least two (2) years of recent clinical practice or one (1) year of recent utilization review experience is required.

• Strong analytical and conceptual thinking skills.

• Exceptional judgment, problem-solving abilities, and discretion.

• Capacity to manage work-related stress effectively.

• Ability to prioritize multiple tasks concurrently.

• Capability to meet deadlines consistently.

• Proficient keyboarding skills.

• Adequate hearing, vision, and verbal communication skills.

🏝️ Benefits

• Blended work environment.

• Continuous learning and professional development opportunities.

• A diverse and extensive benefits package.

• Three medical plan options available.

• Two dental plan options available.

• Eligibility for tuition reimbursement.

• 401K plan matching 50% of contributions up to the first 6% saved.

• Four weeks of PTO during the initial full year.

• Vision insurance.

• Disability insurance.

• Life insurance.

• Employee assistance program.

• Flexible spending or health savings account.

• Additional voluntary benefits.