Utilization Review Nurse

We are looking for a Registered Nurse experienced in Utilization Review, looking to work within a diverse population.

Some responsibilities include...

• Assessing patient care, review medical records and care plans to make sure that treatments are necessary and effective. Evaluating how well resources are being used.
• Deciding on coverage, determining if patient's healthcare insurance will cover specific care. Walk patients through their insurance options and limitations.
• Collaborate with insurance companies, social work, and quality improvement teams
• Making recommendations
• Help determine how long a patient should stay in the hospital, and if the care plan is effective.
• Evaluating clinical appeals, assess patient care services in clinical appeals to decide if they should be approved or denied
• Looking at 15 cases a day, Pediatrics as well as adults form 18-25 of age

Looking for indivduals with...

• Health plan experience
• Hospital experience
• Interqual or Miliman experience
• Experience in health plans reviews (dermal medicine, home health, rehab)
• Pediatric inpatient admissions is a plus
• Authorization, long term care, skilled nursing, behavioral analysis is a plus

Training in person. After training, the obligation is one day per week in the office based on the employees decision to select.

Monday-Friday full time role

8:00-5:00pm