Utilization Review Nurse

Identify potential quality-of-care issues, service delays, and treatment delays, and intervene as clinically appropriate. Conduct prospective reviews and make first-level determination approvals using evidence-based guidelines, organizational policies, and nationally recognized clinical criteria.

Nurse RN 5


Job Summary

Provides and coordinates patient care, educates patients and the public about health conditions, and offers medical guidance and emotional support. Performs utilization management activities, including clinical reviews, authorization determinations, care coordination, and compliance monitoring.

Responsibilities

• Conduct prospective reviews and make first-level determination approvals using evidence-based guidelines, organizational policies, and nationally recognized clinical criteria.
• Verify that diagnoses correspond with applicable ICD-10 codes.
• Triage and prioritize cases to meet required regulatory turnaround times.
• Expedite access to appropriate care for members with urgent needs by using the expedited review process.
• Develop determination recommendations and present cases to the Medical Director when a treatment denial requires review.
• Communicate determinations to providers and members in compliance with state, federal, and accreditation requirements.
• Prepare and review member-centered documentation and correspondence that accurately reflects determinations.
• Identify potential quality-of-care issues, service delays, and treatment delays, and intervene as clinically appropriate.
• Identify potential third-party liability and coordination-of-benefits cases and notify the appropriate internal departments.

Requirements

• Associate degree in nursing required;bachelor s degree preferred.
• Active nursing license required.
• At least 10 years of nursing experience required.
• Experience in prior authorization, post-service review, concurrent review, inpatient hospital settings, or utilization management required.
• Knowledge of the Nurse Practice Act and the legal implications of nursing actions.
• Knowledge of clinical practices and techniques used to assess and treat injuries and diseases.
• Ability to analyze data and accurately document and record results.

Skill

• Verbal and written communication
• Attention to detail
• Problem-solving and analytical ability
• Time management and ability to work independently
• Clinical review and utilization management
• Accurate documentation and recordkeeping

Summary Qualification

• Licensed registered nurse with extensive clinical and utilization management experience.
• Experienced in authorization reviews, concurrent reviews, post-service reviews, and inpatient care assessments.
• Skilled in applying clinical criteria, evaluating medical necessity, and making appropriate determinations.
• Knowledgeable about regulatory, accreditation, coding, and nursing practice requirements.

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.