Utilization Review Nurse Auditor

This is a fully remote position, open to applicants in New Jersey.

📋 Description

• Conduct quality utilization reviews utilizing acquired knowledge and evidence-based guidelines.

• Approve care that is deemed medically necessary and appropriate.

• Complete peer review documentation, including reports, correspondence, addendums, and supplemental reviews.

• Collaborate directly with providers to determine the level, intensity, and duration of care needed.

• Document findings and assess medical necessity regarding the frequency, intensity, and length of care.

• Ensure reviews align with industry standards and meet required client, federal, state, or URAC turnaround times.

• Stay informed about URAC and state and federal regulatory requirements.

• Keep accurate records of utilization reviews in the designated database.

• Guide Customer Service Representatives to guarantee timely issuance of determination letters.

• Address client complaints and quality assurance concerns effectively.

• Ensure adherence to federal ERISA, URAC, state guidelines, client agreements, and regulatory standards.

• Provide management with insights regarding compliance issues.

• Actively participate in company meetings, training sessions, and ongoing education.

• Undertake additional duties as assigned.

⛳️ Requirements

• High school diploma or equivalent is mandatory.

• Graduate from an accredited nursing program is required.

• An active, unencumbered Registered Nurse, Licensed Practical Nurse, or Licensed Vocational Nurse license is necessary.

• A minimum of three to five years of direct professional patient care experience is preferred.

• Background in utilization management is an advantage.

• Strong understanding of medical terminology, anatomy and physiology, treatment protocols, medications, and laboratory values is essential.

• Proficient typist with a minimum typing speed of 40 W.P.M.

• Competent in operating a computer, fax machine, copier, scanner, and telephone.

• Familiarity with various software applications, including Microsoft Suite, is required.

• Capability to accurately follow instructions and management directives.

• Attention to detail, thoroughness, accountability for quality, and a proactive approach to identifying improvements are vital.

• Ability to work independently, prioritize tasks, and utilize time efficiently.

• Maintain confidentiality at all times.

• Foster a positive, team-oriented work environment.

• Capable of remaining focused and performing under pressure or stressful conditions.

• Ability to manage changes, delays, or unexpected events in a professional manner.

• Adherence to company policies and procedures is crucial.

🏝️ Benefits

• Medical, vision, and dental coverage.

• Paid time off.

• 401k retirement plan.

• Continuing education opportunities.

• Participation in company meetings and training activities.