Utilization Review Nurse Auditor

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

📋 Description

• Conduct quality utilization review services and authorize necessary and appropriate medical care based on evidence-based guidelines and criteria.

• Prepare peer review reports, correspondence, appendices, and additional reviews.

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

• Record findings and evaluate the medical necessity concerning the frequency, intensity, and length of care.

• Ensure that reviews comply with industry standards and meet the turnaround times set by clients, federal, state, or URAC regulations.

• Stay updated on URAC and state and federal regulatory requirements.

• Keep precise utilization review records in the designated database.

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

• Support the resolution of client complaints and address quality assurance issues.

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

• Provide management with insights on compliance issues related to products, company policies, procedures, and client specifications.

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

• Execute other assigned responsibilities.

⛳️ Requirements

• High school diploma or equivalent is mandatory.

• Graduate from an accredited nursing program is required.

• Must possess an active and unencumbered Registered Nurse, Licensed Practical Nurse, or Licensed Vocational Nurse license.

• 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.

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

• Proficient in using a computer, fax machine, copier, scanner, and telephone.

• Familiarity with various software applications, including Microsoft Suite.

• Ability to accurately follow instructions and management directives.

• Demonstrated accuracy, thoroughness, responsibility for quality, initiative, and capability for quality improvement.

• Capacity to work independently, prioritize tasks, and efficiently manage time.

• Commitment to maintaining confidentiality.

• Ability to thrive in a positive, team-oriented environment.

• Capability to stay focused and perform under pressure or stressful situations.

• Ability to effectively manage changes, delays, or unexpected events.

• Compliance with company policies and procedures is essential.

🏝️ Benefits

• Medical, vision, and dental coverage.

• Paid time off.

• 401k retirement plan.

• Continuing education opportunities.

• Company-sponsored training activities.

• Fully remote work arrangement.