Utilization Review Nurse - WFH

Job Purpose  

The Utilization Management Review Nurse reviews the medical necessity and appropriateness of healthcare services and treatments through the medical information of individual patients and the limited insurance coverage available to them. The Utilization Management Review Nurse works with healthcare providers, insurance companies, and patients to ensure the quality of patient care is cost efficient.  

Duties and Responsibilities 

• Conducts pre-certification, inpatient, retrospective reviews, in accordance with UM policies and procedures.
• Conducts initial medical necessity reviews. Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
• Collaborate with healthcare providers to promote the most appropriate, highest quality member outcomes, and to optimize member benefits.
• Conducts initial benefit determination reviews.
• Consults with UM Medical Director to review requests that do not meet medical necessity.
• Performs continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Generates appropriate written correspondence to providers and/or members in accordance with UM policies and procedures.
• Adheres to company policies and procedures regarding confidentiality and privacy. 

Qualifications 

• Must have valid PHRN License; USRN license is a plus.
• Minimum of 1 year experience in Utilization Management.
• Experience utilizing UM criteria including MCG or InterQual.
• Minimum of three (2) years clinical nursing experience in an ambulatory or hospital setting.
• Proficient computer skills and experience with Microsoft web-based applications.
• Experience in managed care and health insurance required.
• Ability to communicate effectively English, both written and verbal.
• Ability to work holiday and weekend rotation. 

Working Conditions

• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
• Work Environment: The noise level in the work environment is usually minimal.

Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.