Utilization Review Nurse

remote within one of our plan states, IL, TX, NM, OK, MT or TN

Registered Nurse responsible for collaborating with healthcare providers, members, and business partners, to optimize member benefits, evaluate medical necessity and promote effective use of resources. Medical necessity reviews may include: drugs and biologics, inpatient admissions, outpatient services, surgical and diagnostic procedures, home health, durable medical equipment and out of network services. Conduct reviews in compliance with medical policy, member eligibility, benefits, and contracts.

Essential Duties and Responsibilities:
Responsible for the effective and sufficient support of all Utilization Management activities to include review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies and compliance guidelines.
Uses an established set of criteria to evaluates and authorize the medical necessity of services.
Provide notification of decisions in accordance with compliance guidelines.
Coordinate with Medical Directors when services do not meet criteria or require additional review.
Participation in staff meetings, regular trainings and other collaborative meetings as appropriate.
Works with management team to achieve operational objectives and financial goals.
Supports teams across UM Department as needed.
Active participation and completion of all required trainings.
Maintain Required Licensures.
Adherence to regulatory and departmental timeframes for review of requests
Meet/exceed department Turn Around time, daily established productivity goals, and service levels
Proficient knowledge of policies and procedures, Medicare, HIPPA and NCQA standards;
Professional demeanor and the ability to work effectively within a team or independently;
Flexible with the ability to shift priorities when required
Other duties as required

Qualifications:
Current unrestricted RN license. Multi-State License Preferred
Bachelors degree in nursing or health-care related field preferred
Minimum of 2 years experience in a regulated environment preferred
Minimum of 2-3 years clinical experience
Strong customer orientation
Strong organizational, planning, and communication skills
Working knowledge of insurance industry, medical coding (CPT/HCPCS/ICD-10), and overall claims process a plus
Knowledge of National Coverage Determinations, Local Coverage Determinations and MCG criteria are a plus.
Excellent time management skills


Knowledge, Skills, Abilities Required:
Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workers involved in the care of a member
Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments
Able to work in a dynamic, fast-paced team environment and to promote team concepts
Excellent typing skills.
Substantial knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel and Word.