Utilization Review Nurse
New
United StatesFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- 3+ years of clinical nursing experience as an RN, 2+ years of utilization management experience
- Required Skills
- Microsoft OfficeCompliance
Requirements
- 3+ years of clinical nursing experience as an RN, preferably in a hospital setting
- 2+ years of utilization management experience in a health plan UM department
- Valid Compact RN License
- Proficiency in conducting prospective, concurrent, and retrospective reviews using standardized criteria and guidelines like MCG
- Ability to review and interpret medical records, treatment plans, and clinical documentation
- Thorough understanding of healthcare policies, insurance guidelines, and regulatory standards (e.g., Medicare, NCQA, TRICARE)
- Familiarity with coding systems like ICD-10 and CPT
- Technical savvy and ability to navigate multiple systems and screens
- Computer proficiency in Microsoft Office products including Word, Excel, and Outlook
Responsibilities
- Review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity
- Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews
- Manage the review of medical claims disputes, records, and authorizations
- Coordinate transitions of care and referrals to Care Management
- Complete all documentation of reviews and decisions according to compliance requirements
- Participate as a member of an interdisciplinary team in the Health Management Department
- Maintain knowledge of applicable regulatory guidelines and department policies
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