Job Description

Job Title: Utilization Review Nurse

Location: Remote in IL, TX, NM, MT or OK

Duration: 6+ months contract (possible extension)

Pay: $41.45/hr on W2

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.

Qualifications:

• Current unrestricted RN license. Multi-State License Preferred

• Bachelor’s 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

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