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Related keywords
- Utilization Review Manager
- Utilization Review Nurse
- Utilization Review Coordinator
- Utilization Review Specialist
- Utilization Review Rn
- Utilization Review Asst
- Utilization Review Assistant
- Case Management Utilization Review Rn
- Continuing Care Utilization Review Coordinator Rn
- Rn Utilization Review Full Time Rrmc
Utilization Review Rn - Remote
Company | Guidehouse |
Address | District of Columbia, United States |
Employment type | FULL_TIME |
Salary | |
Category | Business Consulting and Services |
Expires | 2023-06-15 |
Posted at | 11 months ago |
Job Family
- Completes documentation in a timely, complete, and accurate manner in accordance with client benefits, guidelines, and regulatory requirements.
- Supports the care management model as a working partner with providers, facilities, care managers, social workers, pharmacists, and other professional staff.
- Demonstrates a solid understanding of managed care trends, payer regulations, reimbursement, and the effect on utilization and outcomes of the different methods of reimbursement.
- Implements a discharge plan to prevent avoidable days or delays in discharge.
- Identify and refer complex risk members to care management.
- Other duties as assigned.
- Identify documents and refer cases to the Physician Advisor for medical review when services do not meet medical necessity criteria, the appropriate level of care, and/or potential quality issues.
- Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to address utilization/resource and progression of care issues. Assists in developing and implementing an improvement plan to address issues.
- Able to adhere to communicated utilization management productivity metrics, including call volume and reviews.
- Experience and knowledge of clinical guidelines/criteria and the accurate application during a clinical review. Maintains objectivity in decision making by utilizing facts to support decisions.
- Must be proficient in various word processing, spreadsheet, graphics, and database programs, including Microsoft Word, Excel, PowerPoint, Outlook, etc.
- Transition individuals to next level of care in coordination with facility Discharge Planner.
- Able to adhere to quality standards for utilization management per policy, including appropriate documentation in alignment with guidelines, strict adherence to turn around time, identification of deviations from the progression of care, initiation of a discharge plan, and communication of barriers to other team members.
- Utilizes resources efficiently and effectively.
- Personal responsibility, respect for self and others, innovation through teamwork, dedication to caring and excellence in customer service.
- Ability to work under a timeline/deadline & provide clear & accurate updates to project leader of assignment progress, hours worked & expected outcomes daily.
- Minimum of 3 years clinical experience. Minimum of 2 years Utilization Management experience.
- Current Registered Nurse license in the state of hire.
- Clinical Denials Experience required
- Familiarity with medical records assembly & clinical terminology, coding terminology additionally beneficial.
- Ability to independently & accurately make decisions and assimilate multiple data sources or issues related to problem solving.
- Graduate of an accredited school of nursing, RN.
- Attention to detail, strong organizational skills and self-motivated.
- Bachelor’s or master’s degree in Nursing.
- California Nursing License
- Health plan based utilization review.
- Emergency Back-Up Childcare Program
- Basic Life & Supplemental Life
- Personal and Family Sick Time & Company Paid Holidays
- Short-Term & Long-Term Disability
- Medical, Rx, Dental & Vision Insurance
- Parental Leave
- Employee Referral Program
- Tuition Reimbursement, Personal Development & Learning Opportunities
- Corporate Sponsored Events & Community Outreach
- Skills Development & Certifications
- Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
- 401(k) Retirement Plan
- Position may be eligible for a discretionary variable incentive bonus
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