Utilization Review Nurse Jobs

*************************Work from Home.*********************************************

***************************MUST HAVE MEDCOMPASS or ASSURECARE*************

• Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care.
• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.

Required Qualifications :

2 plus years Managed Care experience

3+ years of experience as an RN

1+ years of inpatient hospital experience

Registered Nurse in state of residence

Must have prior authorization utilization experience

Responsible for the review and evaluation of clinical information and documentation.

Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required.

Requires an RN with unrestricted active license

M-F 8-5 EST (some flexibility)

Fully remote (never coming onsite)