Our team is currently seeking a full-time Utilization Management (UM) Nurse (REMOTE) to oversee the utilization review process. This role involves ensuring timely assessments of treatment requests for medical necessity, promoting cost-effective care, and enhancing patient outcomes. The UM Nurse will conduct initial clinical reviews, prepare case summaries, issue certifications of medical necessity, and collaborate with peer clinical reviewers as needed.
Key Responsibilities
Coordinate the utilization review process for each treatment request.
Provide clinical oversight and support to non-clinical staff.
Conduct initial clinical reviews based on evidence-based guidelines.
Evaluate the necessity for continued or alternative treatments.
Communicate treatment options with requesting providers.
Document utilization review activities within the Utilization Management System, adhering to State, Federal, and URAC standards.
Collaborate with peer clinical reviewers and facilitate peer discussions during the review process.
Partner with medical providers to optimize patient outcomes.
Adhere to Policies, Procedures, and URAC standards.
Assist in promoting the Quality Management Program's objectives.
Maintain confidentiality and security in all aspects of work.
Perform other related duties as assigned.
Qualifications
Education/Licensure/Certification:
Completion of formal training in a healthcare field.
Active, unrestricted professional license or certification to practice as a health professional in a US state or territory:
Associate degree or higher in a healthcare field (RN) OR
State license or certificate in a healthcare field (LVN/LPN)
Certified Case Manager (CCM), Health Care Quality & Management (HCQM), or equivalent certification preferred.
Skills
Knowledge of workers' compensation laws and regulations (preferred).
Discretion and confidentiality.
Strong customer service, oral, and written communication skills.
Proficiency in Microsoft Office and other computer applications.
Ability to work collaboratively in a team environment.
Analytical, interpretive, organizational, interpersonal, and negotiation skills.
Ability to multitask effectively.
Experience
2 years of clinical nursing experience (direct patient care, administrative, or a combination post-licensure).
1 Year Of Experience With Workers' Compensation/utilization Management Preferred.
Working Conditions
100% remote role.
Work environment: Indoors, office setting, or home office.
Prolonged periods of sitting and typing, with intermittent breaks, up to 8 hours per day.
Regular use of computer monitor, telephone, instant messaging software, and email communication.
Pay Range: $63,000-$75,000
Location: Remote (US)
Employment Type: Full-Time, Salary (Exempt)
An equal opportunity employer that values diversity and does not discriminate based on religious creed, sex, national origin, race, veteran status, disability, age, marital status, color, or sexual orientation, or any other characteristic protected by law. Background checks will be conducted in accordance with local state laws and regulations.
Employment Type: Full-Time
Seniority level
Entry level
Employment type
Full-time
Job function
Health Care Provider
Industries
Human Resources Services
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