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The Utilization Review Nurse will provide professional assessments and review for the medical necessity of treatment requests and plans. The standard work schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekend coverage required.
Job Responsibility:
Provide professional assessment and review for the medical necessity of treatment requests and plans
Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness
inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity
and post claim or post service reviews
Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO)
Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care
Refer requests that fall outside of established guidelines to advance review or senior care consultants
Process appeals for non-certification of services, complete non-certification letters when appropriate
Review plan document for benefit determinations
attempt to redirect providers and patients to PPO providers
Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together programs
Complete documentation for all reviews in appropriate documentation software
Utilize guidelines in appropriate hierarchy. Guidelines include MCG guidelines, internal medical policies, group specific policies, and NCCN
Ability to meet productivity, quality, and turnaround times daily
Ability to pass external audits to include URAC and NCQA
Maintain HIPPA compliance per company’s policy and procedures
Maintain confidentiality and minimum requirement rules
Complete all required yearly training per company’s expected time limit
Complete and pass all annual testing including IRRA at 90% or higher
Requirements:
Current RN license in the United States or U.S. territory
Associate’s degree or diploma (Nursing program) required
1+ year clinical experience required
Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards
Ability to maintain regular, punctual attendance
Ability to sit for 6-8 hours
Constant use of computer keyboard and mouse
repetitive use of both hands
Occasional to frequent twisting of neck
occasional bending of neck and at waist
Must be able to remain in a stationary position 50% of the time
The person in this job needs to occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities
Constantly operates a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc.
Frequently positions self to maintain files in file cabinets
Frequently moves boxes or equipment weighing up to 25 pounds
Must communicate information and ideas so others understand. Must be able to exchange accurate information in these situations
Must be able to observe details at close range
What we offer:
Competitive base salary and benefits effective day one
Comprehensive medical and dental through our own health solutions
Paid Time Off
Mental health support, retirement planning, and financial protection
Professional development with clear career progression and learning budgets