Utilization Management Review Nurse

This is a full-time remote work from home position.

The utilization management review nurse will conduct reviews for hospitalizations, post-acute admissions, prior authorizations, and appeals. They will condense the information that is provided and use national standard guidelines to determine if the clinical information received meets criteria. They will work collaboratively with both medical directors and case managers.

• Use clinical experience to assess, plan, implement, coordinate, monitor, and evaluate options to ensure appropriate healthcare services/benefits for members.
• Collect clinical information and applies the appropriate clinical criteria/guideline, policy, and clinical judgment to provide coverage determination.
• Communicates with providers and other parties to facilitate care.
• Identifies members for referral opportunities.
• Ability to work autonomously
• Ability to multi-task, prioritize and effectively adapt to a fast-paced changing environment.
• Strong written and verbal communication skills.
• Intermediate typing skills.
• Demonstrated organizational skills and communication skills required.
• Ability to learn and retain in a complex environment.
• Ability to seamlessly, multi-task while using multiple system for a review.
• This position may require working weekends and/or holidays.
• This role involves sitting for extended periods and using a computer extensively.
• Must have high speed internet access – preferably ethernet connection.

Qualifications:

• 3+ years of experience as a registered nurse or licensed practical nurse
• Must have an active and unrestricted nursing license in (state – this will be dependent on the state and if they are compact or if they are single state licenses. This section will change pending the state)
• 1+ years of med/surg experience - preferred
• Experience with Microsoft Office Applications (Outlook, Teams, Excel, Word)