Utilization Review Nurse
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
Utilization Review Nurse conducting remote workers’ compensation utilization reviews. Evaluating medical necessity, coordinating discharge planning, and referring cases for case management.
Responsibilities:
- Conduct first-level prospective, concurrent, expedited, and retrospective utilization management reviews
- Review inpatient services, outpatient services, surgeries, and ancillary service requests
- Evaluate treatment requests and clinical information using state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria
- Identify medical necessity and refer cases to a Peer Physician when appropriate
- Complete reviews within state jurisdiction and URAC timeframes
- Review inpatient length of stay when applicable
- Arrange alternative care services and discharge planning
- Identify patients with ongoing case management needs and refer claimants to the Case Management team
- Identify and review potential safety issues with the Medical Director
- Promote cost-effective healthcare through an aligned provider network
- Refer cases to Telephonic Case Management and Pharmacy TCM
- Coordinate with TCM and Pharmacy TCM on appropriate next steps
- Manage determinations within the pharmacy portal
- Perform NY PAR in the onboard system according to NY MTG Guidelines
- Maintain documentation standards, confidentiality, billing, productivity, time management, and quality assurance requirements
- Perform other assigned duties
Requirements:
- Diploma, Associate, bachelor’s degree in nursing, or Master’s level (or higher) degree in a Nursing, Health or Human Services field, or equivalent related experience preferred
- A current, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license recognized in the relevant jurisdiction(s) is required
- Interstate nurse compact licensure is preferred
- May be required to obtain additional licensure based on jurisdictional assignment
- CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred
- Experience with Workers’ Compensation utilization review
- Knowledge of state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria
- Knowledge of URAC timeframes and standards
- Knowledge of HIPAA and PHI laws and regulations
- Ability to meet productivity, time management, quality assurance, billing, and documentation requirements
- Ability to perform NY PAR in the onboard system in accordance with NY MTG Guidelines
Benefits:
- Medical, Dental, Vision Insurance
- Life and Disability Insurance
- 401(k) Plan
- Paid Holidays
- Paid Time Off
- Referral bonus
- Fully remote work arrangement
Similar Jobs
Registered Nurse, CA RN License Required
Remote Registered Nurse delivering virtual geriatric primary care for Pine Park Health. Coordinating assessments, triage, care plans, and chronic-care support for senior living residents.
Case Manager, Registered Nurse
Remote RN Case Manager coordinating CVS Health members’ clinical care, benefits, and wellness. Assessing needs and managing care through telephonic and face-to-face member engagement.
Case Manager, Registered Nurse
Remote RN Case Manager coordinating telephonic and face-to-face care for CVS Health members. Assessing medical needs, benefits, risks, and wellness outcomes.
Case Manager, Registered Nurse
Remote RN Case Manager assessing members and coordinating care plans for CVS Health. Supporting wellness through clinical judgment, benefits review, and case management.
Clinical Review Nurse – Concurrent Review
Clinical Review Nurse conducting concurrent utilization reviews for Centene’s Medicaid and Ambetter members. Evaluating medical necessity, care levels, and discharge planning remotely.
Utilization Review Nurse
Utilization Review Nurse reviewing emergency admissions and continued stays using InterQual or MCG criteria. Supporting authorization decisions and appropriate healthcare resource utilization at Netsmart.
Registered Nurse, Case Manager, Care Coordination
RN case manager coordinating patient-centered care for Geisinger Health Plan. Assessing needs, developing care plans, and optimizing clinical, quality, and fiscal outcomes.
Virtual Oncology Nurse Navigator
Virtual oncology nurse navigator delivering triage, education, and care coordination. Supporting Daymark Health’s personalized cancer care platform through phone and virtual care.
National Virtual Oncology Nurse Navigator
National virtual oncology nurse navigator providing triage, care coordination, and patient education. Supporting Daymark Health’s value-based cancer care platform through virtual patient care.
Mobile Nurse – Healthcare Professional
Mobile nurse conducting venous blood draws and workplace health screenings for HealthCaters. Event-based assignments at company locations across Germany, with occasional European opportunities.
Clinical Trial Nurse Navigator – Grant Funded
Clinical Trial Nurse Navigator helping blood cancer patients identify and enroll in clinical trials at Blood Cancer United. Educating families on treatment options and supporting informed care decisions.
Registered Nurse Care Manager
Registered Nurse Care Manager coordinating assessments, authorizations, and care plans for CareSource members. Mobile role serving Brooklyn homes and care settings with extensive travel.
Clinical Review Nurse – Concurrent Review, NICU
Clinical Review Nurse conducting concurrent NICU reviews for Centene’s Medicaid and marketplace members. Evaluating medical necessity, care levels, and discharge planning remotely.
Utilization Management Nurse
Utilization Management Nurse coordinating medical services and benefit determinations for Humana, a U.S. healthcare and insurance company. Applying clinical criteria to support optimal member care.
Registered Nurse, Virtual Hiring Event
Registered Nurse hiring event for Wellstar MCG Health in Augusta, Georgia. Exploring acute, critical, emergency, labor and delivery, pediatric, and neonatal care opportunities.
Nurse Navigator – FIND Program
Remote Nurse Navigator coordinating follow-up for patients with incidental radiological findings. Supporting Trinity Health care teams through education, referrals, and care navigation.
Triage Registered Nurse, Hospice
Part-time remote hospice triage RN assessing patients by phone and coordinating palliative care. Sequoia Hospice serves patients and families through home health and hospice services.
Medical Insurance Specialist – Registered Nurse
Remote Registered Nurse verifying U.S. insurance benefits and managing eClinicalWorks scheduling. Driving patient engagement and appointment conversions for an orthopedic, pain medicine, and PM&R practice.
Travel Flight Nurse
Travel Flight Nurse delivering critical helicopter patient care for Air Methods. Assessing, treating and transporting patients on rotating 14-day assignments.
Freelance Research Nurse
Freelance research nurse supporting Illingworth’s patient-focused clinical research services. Conducting trial visits, medication administration, sample handling, and adverse-event reporting in Lille, France.