Utilization Review Nurse Auditor

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

📋 Description

• Conduct quality utilization reviews using acquired expertise and evidence-based guidelines for peer review reports, correspondence, addendums, and supplementary evaluations.

• Collaborate directly with healthcare providers to ascertain the level, intensity, and duration of care required.

• Record findings and continuously assess the medical necessity for the frequency, intensity, and length of care needed.

• Ensure that the consistency and quality of reviews meet or surpass industry standards.

• Complete quality reviews within the stipulated turnaround times mandated by clients, federal, state, or URAC standards.

• Maintain and apply up-to-date knowledge of URAC and other state and federal regulatory requirements.

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

• Guide Customer Service Representatives to ensure prompt delivery of determination letters.

• Assist in addressing client complaints and quality assurance matters.

• Ensure adherence to federal ERISA, URAC, and other state regulations.

• Provide management with insights and guidance regarding compliance issues.

• Engage in company meetings, training sessions, and ongoing education opportunities.

• Carry out other assigned responsibilities.

⛳️ Requirements

• High school diploma or equivalent is mandatory.

• Must be a graduate of an accredited nursing program.

• An active, unrestricted Registered Nurse, Licensed Practical Nurse, or Licensed Vocational Nurse license is required.

• Willingness to obtain CPC certification within the first six months of employment is essential.

• Certifications such as OASIS, RAC-CT, CCS, CPC, RHIT, RHIA, or CPMA are preferred.

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

• Experience in utilization management is preferred.

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

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

• Capability to operate general office equipment, including computers, fax machines, copiers, scanners, and telephones.

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

• Ability to follow instructions and respond accurately to directives from upper management.

• Must demonstrate accuracy, thoroughness, and responsibility for the quality of work, along with the initiative to identify areas for improvement.

• Ability to work independently, prioritize tasks, and manage time effectively.

• Must maintain confidentiality at all times.

• Ability to foster and promote a positive team-oriented atmosphere.

• Ability to maintain focus and concentration amidst frequent interruptions, while working under pressure or in stressful situations.

• Capability to handle changes, delays, or unexpected events appropriately.

• Must adhere to all company policies and procedures.

🏝️ Benefits

• Medical insurance

• Vision insurance

• Dental insurance

• Paid time off

• 401k

• Competitive benefits

• Continuing education requirements