Senior Virtual Utilization Review Specialist
New
We are seeking Senior Virtual Utilization Review Specialists in Pacific Time and Mountain Time, Pacific Time, Mountain TimeFull-TimeSenior
Salary not disclosed
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Job Details
- Experience
- Three years nursing experience in an acute care environment preferred
Requirements
- Bachelor's Degree or equivalent experience in Nursing or related field.
- Current unrestricted LPN or RN compact licensure.
- Willingness to obtain single state licensure in Oregon and Alaska.
- Three years of nursing experience in an acute care environment (preferred).
- Utilization review or discharge planning experience (preferred).
- Working knowledge of medical necessity review criteria and quality improvement processes.
- Access to high-speed internet.
- Strong clinical assessment, organization, and problem-solving skills.
- Excellent interpersonal and negotiation skills.
- Ability to work independently and collaboratively in a fast-paced environment.
Responsibilities
- Utilize proactive triggers to identify potential over/under utilization of services.
- Conduct medical necessity review of all admissions using approved clinical criteria.
- Collaborate with financial clearance centers, physicians, and care management staff.
- Manage denials, coordinate the P2P process, and maintain appeal documentation.
- Monitor readmission trends and perform statistical data entry.
- Facilitate patient care prioritization based on situational analysis and medical records.
- Educate hospital and medical staff regarding utilization review programs.
- Maintain clinical competency and knowledge of regulatory requirements.
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