Utilization Management Registered Nurse / Remote

About the Position

The Utilization Review Nurse ensures that authorization requests, provider and member clinical inquiries are processed timely and handled appropriately within member's plan benefits coverage and established clinical guidelines utilized for appropriate clinical decision-making. Functions collaboratively with individuals within the Utilization Management team, and specifically with the inpatient review nurses, Case Managers, and Medical Directors to ensure timely determination of inpatient and outpatient medical services authorization requests.

Responsibilities

• Perform review of requests for services/procedures including elective surgery, skilled nursing facility and therapy services, durable medical equipment (DME), and supplies.
• Use established medical criteria to approve services based on information obtained from attending physicians and providers.
• Ensure full collection of clinical information and timely determination of requests.
• Consult with Medical Directors for requests that do not meet criteria.
• Act as a member/family advocate in coordinating and accessing medical necessity health care services.
• Manage workload needs on a concurrent basis, including authorization and fax queues.
• Support on-boarding program for UM staff by acting as primary mentor.
• Participate in process improvement initiatives.

Requirements

• Current license (without restriction) to practice as a Registered Nurse (RN) with a multistate license.
• Knowledge of medical/surgical terminology and Medicare managed care authorization processes.
• Effective verbal and written English communication skills.
• Demonstrated intermediate to advanced skills in Microsoft Office Suite.
• Strong attention to detail, analytical, and problem-solving skills.