Utilization Review Nurse

Position Description

This is a remote work-from-home position. The Utilization Review Nurse is responsible for performing initial, concurrent or retrospective utilization review of medical records, applying industry-recognized guidelines and rendering a first level clinical determination of medical necessity. The Utilization Review Nurse will need to identify cases where additional information is required and communicate this effectively to clients. The Utilization Review Nurse must use nursing judgement to identify the need for a second level review and collaborate with the Medical Director to ensure that the review is completed timely and the result is effectively communicated to the client.

Qualifications:

Critical Skills

  • Advanced knowledge of utilization review procedures
  • Working knowledge of InterQual®/MCG Guidelines®
  • Computer literacy
  • High Speed Internet connection and a HIPPA compliant workspace
  • Capable of meeting deadlines with little supervision
  • Excellent written and oral communication skills

Preferred Skills

  • 3 Years of Acute Care Utilization Review experience with a focus in case management, utilization review, or prior authorization and appeals is strongly preferred
  • Good understanding of health-service related processes relevant to the acute care setting.
  • Analytical thinking with the ability to problem solve.
  • Good knowledge of case management specific-regulatory healthcare documentation requirements.

Certification and Licensure

  • Registered Nursing Licensure-Unrestricted
  • Professional certification in Case Management (CCM or ACMA) preferred

Physical Requirements

  • Capable of performing general office demands
For consideration, please submit resumes to careers@Preadmit.com