Utilization Review Nurse Auditor

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

📋 Description

• Conduct quality utilization reviews based on evidence-based guidelines.

• Authorize care that is deemed medically necessary and appropriate.

• Create peer review reports, correspondence, addendums, and supplementary reviews.

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

• Assess the medical necessity for the frequency, intensity, and duration of required care.

• Ensure that reviews comply with industry quality standards and mandated turnaround times.

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

• Keep accurate utilization review records in the designated database.

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

• Assist in addressing client complaints and quality assurance matters.

• Ensure adherence to ERISA, URAC, and other relevant guidelines.

• Provide management with insights regarding compliance issues.

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

• Carry out other assigned responsibilities.

⛳️ Requirements

• High school diploma or equivalent is required.

• Graduate from an accredited nursing program.

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

• Current coding certification in OASIS, RAC-CT, CCS, CPC, RHIT, or RHIA is required.

• CPMA certification is preferred.

• 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 lab values.

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

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

• Familiarity with Microsoft Suite and various software programs.

• Ability to maintain confidentiality.

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

• Ability to perform under pressure and handle interruptions or unexpected situations.

• Capability to adhere to company policies and procedures.

🏝️ Benefits

• Medical insurance.

• Vision insurance.

• Dental insurance.

• Paid time off.

• 401k.

• Continuing education requirements.

• Company meetings and training activities.

• Fully remote work.

• Competitive benefits.