Utilization Review Nurse Auditor
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Job Description
Utilization Review Nurse Auditor reviewing medical necessity and regulatory compliance for ExamWorks’ healthcare services. Fully remote role producing high-quality utilization review determinations.
Responsibilities:
- Perform quality utilization review services and approve medically necessary and appropriate care using evidence-based guidelines and criteria
- Complete peer review reports, correspondence, addendums, and supplemental reviews
- Work directly with providers to identify the level, intensity, and duration of care
- Document findings and evaluate medical necessity for frequency, intensity, and length of care
- Ensure reviews meet industry standards and client, federal, state, or URAC turnaround times
- Maintain knowledge of URAC and state and federal regulatory requirements
- Maintain accurate utilization review records in the appropriate database
- Direct Customer Service Representatives to ensure timely delivery of determination letters
- Assist with client complaints and quality assurance issues
- Ensure compliance with federal ERISA, URAC, and other state guidelines
- Advise management on compliance concerns involving products, company policies, procedures, and client specifications
- Participate in company meetings, training activities, and continuing education
- Perform other assigned duties
Requirements:
- High school diploma or equivalent required
- Graduate of an accredited nursing program
- Active unencumbered Registered Nurse, Licensed Practical Nurse, or Licensed Vocational Nurse required
- Minimum of three to five years of direct professional patient care required
- Experience in utilization management preferred
- Strong knowledge of medical terminology, anatomy and physiology, treatment protocols, medications, and laboratory values
- Qualified typist with a minimum of 40 W.P.M.
- Ability to operate a computer, fax, copier, scanner, and telephone
- Knowledge of multiple software programs, including Microsoft Suite
- Ability to follow instructions and management directions accurately
- Accuracy, thoroughness, responsibility for quality, initiative, and quality improvement ability
- Ability to work independently, prioritize work activities, and use time efficiently
- Ability to maintain confidentiality
- Ability to work in a positive team-oriented environment
- Ability to remain focused and work under pressure or stressful conditions
- Ability to manage change, delays, or unexpected events appropriately
- Ability to follow company policies and procedures
Benefits:
- Medical, vision, and dental benefits
- Paid time off
- 401k
- Continuing education requirements
- Company training activities
- 100% remote work
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