Utilization Review Nurse Auditor

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

📋 Description

• Conduct quality utilization reviews and authorize medically necessary and appropriate care in alignment with evidence-based guidelines and criteria.

• Prepare peer review reports, correspondence, addendums, and supplemental evaluations.

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

• Record findings and assess medical necessity regarding the frequency, intensity, and duration of care.

• Ensure that reviews comply with industry standards and adhere to required client, federal, state, or URAC turnaround times.

• Keep informed about URAC and other regulatory requirements.

• Maintain precise utilization review records in the designated database.

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

• Assist in addressing client complaints and quality assurance matters.

• Offer management insights on compliance-related issues.

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

• Execute other assigned responsibilities.

⛳️ Requirements

• High school diploma or equivalent is mandatory.

• Must be a graduate of an accredited nursing program.

• Active and unencumbered Registered Nurse, Licensed Practical Nurse, or Licensed Vocational Nurse license is required.

• Must possess a current coding certification in OASIS, RAC-CT, CCS, CPC, RHIT, or RHIA.

• CPMA certification is 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.

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

• Ability to operate a computer, fax machine, copier, scanner, and telephone.

• Familiarity with various software applications, including Microsoft Suite.

• Capable of maintaining confidentiality.

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

• Must adhere to company policies and procedures.

🏝️ Benefits

• Medical, vision, and dental benefits.

• Paid time off.

• 401k plan.

• Collaborative team environment.

• Opportunities for continuing education and training activities.