Utilization Review Nurse

Pay Rate: $42/hr.on w2 

Job Description:
These Utilization Review Nurse positions are for the prior authorization team.
Schedule likely 8 a.m. to 5 p.m. CST or 9 a.m. to 6 p.m. CST/PST/EST
May need to work weekends/holidays at times and may need to work
Must have an RN license – WA/FL/IL/NM/TX/OH
Must have 2+ years of experience with prior authorization, Utilization Review and MCO/InterQual experience.

Job Summary
Works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES
Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
Analyzes clinical service requests from members or providers aProductst evidence based clinical guidelines.
Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
Conducts prior authorization reviews to determine financial responsibility for *** and its members.
Processes requests within required timelines.
Refers appropriate prior authorization requests to Medical Directors.
Requests additional information from members or providers in consistent and efficient manner.
Makes appropriate referrals to other clinical programs.
Collaborates with multidisciplinary teams to promote Client Care Model
Adheres to UM policies and procedures.

JOB QUALIFICATIONS
Completion of an accredited Registered Nurse (RN).

Required Experience
1-3 years of hospital or medical clinic experience.
1+ year Prior Authorization or Utilization Management

Required License, Certification, Association
Active, unrestricted State Registered Nursing (RN) license in good standing.

Day to Day Responsibilities:
Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
Analyzes clinical service requests from members or providers aProductst evidence based clinical guidelines.
Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
Conducts prior authorization reviews to determine financial responsibility for *** and its members.
Processes requests within required timelines.
Refers appropriate prior authorization requests to Medical Directors.
Requests additional information from members or providers in consistent and efficient manner.
Makes appropriate referrals to other clinical programs.
Collaborates with multidisciplinary teams to promote Client Care Model
Adheres to UM policies and procedures.

Required Years of Experience:
2+ years Prior Auth, MCO and/or UM Experience preferred.
Required Licensure / Education: Active, unrestricted State license in good standing (RN)