Utilization Review Nurse

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

📋 Description

• Collaborate closely with the Medical Director to reduce variations in care and facilitate timely discharges.

• Direct members to additional plan resources to address their care needs.

• Report directly to the Health Plan Manager of Utilization Management.

• Act as a vital member and cooperative contributor to 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.

• Carry out care management reviews in accordance with established criteria, clinical guidelines, and policies.

• Ensure collaborative interventions aimed at enhancing members’ healthcare outcomes.

• Comprehend and support the Peer-to-Peer Review process in conjunction with Medical Directors.

• Provide education to internal and external stakeholders and partners.

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

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

• Commit to continuous learning and process improvement within Utilization Management.

⛳️ Requirements

• A current 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).

• A minimum of three (3) years of clinical healthcare experience.

• Familiarity with InterQual and/or Milliman Care Guidelines.

• Proven understanding of federal and state laws, NCQA, and industry regulations related to disease management, utilization management, case management, and discharge planning.

• Exceptional written and verbal communication skills.

• Strong problem-solving abilities to enhance efficiencies and customer satisfaction.

• Keen attention to detail.

• Proficiency in Microsoft Office applications.

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

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

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

• Preferred: Experience in Utilization Management.

🏝️ Benefits

• Full-time position with 40 scheduled hours weekly.

• Exempt status.

• Remote work environment.

• Occasional weekend and holiday work may be required.