Utilization Review Nurse

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

📋 Description

• Conduct first-level prospective, concurrent, expedited, and retrospective utilization management reviews.

• Review requests for inpatient services, outpatient services, surgeries, and ancillary services.

• Assess treatment requests and clinical information based on state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria.

• Determine medical necessity and escalate cases to a Peer Physician when necessary.

• Complete reviews in accordance with state jurisdiction and URAC timeframes.

• Evaluate inpatient length of stay as needed.

• Organize alternative care services and facilitate discharge planning.

• Recognize patients with ongoing case management needs and refer them to the Case Management team.

• Identify and discuss potential safety concerns with the Medical Director.

• Encourage cost-effective healthcare through an integrated provider network.

• Refer cases to Telephonic Case Management and Pharmacy TCM.

• Collaborate with TCM and Pharmacy TCM regarding appropriate subsequent actions.

• Manage determinations within the pharmacy portal.

• Execute NY PAR in the onboard system following NY MTG Guidelines.

• Uphold standards for documentation, confidentiality, billing, productivity, time management, and quality assurance.

• Carry out other assigned responsibilities.

⛳️ Requirements

• A diploma, Associate, bachelor's degree in nursing, or a Master’s degree (or higher) in Nursing, Health, or Human Services, or equivalent related experience is preferred.

• A current, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license recognized in the relevant jurisdiction(s) is required.

• Interstate nurse compact licensure is preferred.

• Additional licensure may be necessary based on jurisdictional assignment.

• Preferred certifications include CCM, CMCN, CPHUR, CPDM, COHN, or CDMS.

• Experience in Workers’ Compensation utilization review is beneficial.

• Familiarity with state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria is essential.

• Understanding of URAC timeframes and standards is required.

• Knowledge of HIPAA and PHI laws and regulations is necessary.

• Capability to meet productivity, time management, quality assurance, billing, and documentation standards.

• Proficiency in performing NY PAR in the onboard system according to NY MTG Guidelines.

🏝️ Benefits

• Medical, Dental, Vision Insurance.

• Life and Disability Insurance.

• 401(k) Plan.

• Paid Holidays.

• Paid Time Off.

• Referral bonus.

• Fully remote work arrangement.