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Utilization Review Nurse

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Full-time Remote 31d ago

Location:

US

Company:

HealthAxis is a prominent provider of core administrative processing system technology, business process as a service, and outsourcing capabilities to healthcare payers.

Summary:

The Utilization Review Nurse will review medical necessity for outpatient services and manage inpatient admissions while collaborating with healthcare providers. Applicants must be licensed RNs or LPNs with at least two to three years of clinical experience.

Requirements:

Hard Skills: Evidence-based guidelines, Clinical documentation analysis, Utilization review processes

Credentials: Licensed RN or LPN

Experience: Minimum of two to three years varied clinical experience required., Managed care experience preferred.

Job Description:

The Utilization Review Nurse is responsible for the medical necessity review of outpatient services that require prior authorization, and/or management of concurrent inpatient admissions. The medical necessity review process includes assessment and interpretation of plan specific benefits, medical criteria, and clinical documentation.

PRINCIPAL RESPONSIBILITIES AND DUTIES:

  • Performs prospective, concurrent, and retrospective inpatient and/or outpatient utilization reviews (UR) using evidence-based guidelines, policies and nationally recognized clinical criteria, and internal policies and procedures.

  • Evaluates severity of illness and intensity of service of member’s needs at time of inpatient admission utilizing approved criteria.

  • Triage and prioritize cases and other assigned duties to meet CMS turnaround time standards.

  • Prepare and escalate cases to MDs for review when appropriate.

  • Demonstrates effective communication methods and skills, using lines of authority appropriately.

  • Establishes a relationship with providers to determine/provide needed services to member.

  • Maintains accurate record of UR activities.

  • Regular attendance is required as employee works as part of a team & requires interaction with medical staff and clients.

  • Adheres to quality standards and confidentiality policies and procedures.

  • Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.

  • Adapts to changes in policies, procedures, new techniques, and additional responsibilities.

CUSTOMER SERVICE:

  • Responsible for driving the HealthAxis culture through values and customer service standards.

  • Accountable for outstanding customer service to all external and internal contacts.

  • Develops and maintains positive relationships through effective and timely communication.

  • Takes initiative and action to respond, resolve and follow up regarding customer service issues with all customers in a timely manner.

EDUCATION, EXPERIENCE AND REQUIRED SKILLS:

  • Licensed RN or LPN required.

  • Minimum of two to three years varied clinical experience required.

  • Managed care experience preferred.

  • An equivalent combination of education, training, and experience.

  • Ability to read and interpret documents and calculate figures and amounts.

  • Excellent oral and written communication skills including good grammar, voice and diction.

  • Proficient in MS Office with basic computer and keyboarding skills.

  • Excellent customer service skills (friendly, courteous and helpful).

  • InterQual experience helpful.