Part Time Utilization Review Nurse, RN

Overview

Personify Health is seeking a Utilization Review Nurse to join our dynamic team with weekend availability and flexible scheduling.

Responsibilities

• Provide professional assessment and review for the medical necessity of treatment requests and plans under the supervision of a registered nurse (RN).
• Conduct first level review for outpatient and ancillary pre-certification requests, inpatient hospital stays, and post claim or post service reviews.
• Ensure proper referral to medical directors for denial authorizations and work with hospital staff for patient discharge planning.
• Process appeals for non-certification of services and complete non-certification letters.
• Review plan documents for benefit determinations and redirect providers and patients to PPO providers.
• Identify and refer potential cases to case management, wellness, chronic disease, and Nurturing Together programs.
• Document all reviews in Eldorado/Episodes and maintain confidentiality.
• Utilize MCG guidelines, medical policies, Medscape, and NCCN while meeting productivity and quality turnaround times.

Qualifications

• Current RN license in the United States or U.S. territory.
• 1+ years of clinical experience.
• Knowledge of medical claims, ICD-10, CPT, and HCPCS coding.
• Proficiency in software applications including Microsoft Word, Excel, PowerPoint, and Outlook.