Utilization Review Nurse (RN)
New
E
Evry HealthHealthcare / Managed Care
Our whole company works remotely. ... We will only consider candidates in the United States who reside in the CST or EST time zones., CST or ESTFull-TimeMiddle
SalaryCompetitive salary
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Job Details
- Experience
- 1-2 years of experience working at a health plan performing utilization management; 3-5 years of clinical experience in a hospital or ambulatory setting
Requirements
- Current, unrestricted Texas or Compact state nursing license.
- Diploma from an accredited school/college of nursing.
- 1-2 years of health plan experience performing utilization management using standard practice guidelines.
- 3-5 years of clinical experience in a hospital or ambulatory setting.
- Working knowledge of medical terminology, insurance terminology, and CPT/ICD10 coding.
- Familiarity with NCQA/URAC standards and digital health programs.
- Ability to work rotating weekend shifts as required.
- Proficiency with technical systems and virtual work tools.
- Must reside in the US and within CST or EST time zones.
- Dedicated private workspace with high-speed internet.
Responsibilities
- Prepare clinical reviews based on organizational guidelines and medical policies.
- Present recommendations to physician reviewers for final determination.
- Conduct prior authorization, concurrent, and retrospective reviews.
- Monitor clinical quality concerns and escalate outlier or complicated cases.
- Interact with external facilities and providers to gather clinical information for medical necessity reviews.
- Assist staff with coding, medical records, documentation, and claims appeals.
- Conduct telephonic outreach to members and perform motivational interviewing.
- Facilitate discharge planning and care coordination.
- Manage departmental escalations with urgency and accountability.
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