Utilization Management Nurse Reviewer

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Requirements:

• Proficient in written and spoken communication.
• Ability to maintain professional communication with physicians and clients.
• Skilled in handling multiple tasks and adapting in a dynamic setting.
• Strong organizational skills and attention to detail.
• Adept at solving complex problems.
• Experienced with Microsoft tools like Word, Excel, PowerPoint, and Outlook.
• Background in medical or clinical practice through education or professional experience.
• Holds an unrestricted LVN/RN license from an accredited program.

Responsibilities:

• Conduct assessments of medical services to validate their appropriateness using established criteria.
• Examine patient records to verify the quality of care and necessity of services.
• Provide clinical expertise and reference support for non-clinical staff.
• Manage clinical details within medical management platforms.
• Stay updated on regulatory prerequisites for utilization review.
• Apply clinical reasoning to evidence-based guidelines.
• Communicate with management, physicians, and the Medical Director to foster patient care.