Utilization Review Nurse (Managed Care )

************Must be in EST/CST.Work from Home.*****************

***********MUST HAVE USED MEDCOMPASS*************

• 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.
• 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.

This position will be working regular business hours with potential for occasional weekend/holiday on-call

Required Qualifications :

2 plus years Managed Care experience

3+ years of experience as an RN

3 - 5 years of inpatient hospital experience

Medcompass required.

MCG (Milliman Care Guidelines) required.

Registered Nurse in state of residence

Must have prior authorization utilization experience

Preferred Qualifications -

• Ambulatory surgery environment experience
• Case Management experience -
• Education Must have at minimum Associates
• Clinical precertification experience -
• Managed care/utilization review experience -

Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations.

Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.

Data gathering requires navigation through multiple system applications.

Staff may be required to contact the providers of record, vendors, or internal departments to obtain additional information.

M-F 8-5 EST (some flexibility)

Fully remote (never coming onsite)