Utilization Review Nurse

Are you ready for your next career adventure as a Remote Utilization Review Nurse in the Washington, DC! Medix Healthcare is currently hiring for a Utilization Review Nurse for a children's health organization. This position will be 100 percent remote (after training) but must have a DC nursing license. Come join a regional health care organization with a TON of opportunity for growth and success!

We offer a competitive benefits package that is on par with most of the leading healthcare organizations, along with a 401K plan. Apply today if you are interested in getting your name in the mix!

Schedule: Monday-Friday 8am-5pm

Location: Training on site in Washington DC for 1 day (equipment & IT set up)

Duties:

• Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using evidenced based guidelines, policies and nationally recognized clinical criteria across lines of business or for a specific line of business
• Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance
• Ensure discharge planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate
• Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements

Experience Requirements:

• Registered Nurse License in DC
• 1-2 years of Utilization Review experience
• Interqual or MCG experience