The Utilization Management Nurse Reviewer plays a pivotal role in healthcare systems, ensuring the efficient and appropriate use of medical services. They meticulously review medical records, treatment plans, and patient information to assess the necessity and suitability of medical procedures, tests, and treatments.
Responsibilities
Collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and uphold quality care standards.
Assess medical necessity, coordinate care, conduct utilization reviews, and provide recommendations for care plans while ensuring compliance with regulations and guidelines.
Utilize strong clinical knowledge and critical thinking skills to make informed decisions regarding patient care pathways.
Serve as a clinical reference for non-clinical staff, input and manage essential clinical data in medical management platforms, and stay current with regulatory and state standards for utilization review.
Requirements
Excellent written and verbal communication skills.
Ability to maintain professional communication with physicians and clients.
Strong organizational skills with keen attention to detail.
Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook).
Background in medical or clinical practice through education, training, or professional experience.
Active LVN/RN license without restrictions.
Additional Responsibilities
Provide oversight to team members, improve processes, and coordinate quality issue reports.
Final approval on cases for client release and liaison with the VP of Clinical Operations.
Education/Credentials
Licensed Practical/Vocational Nurse with an active, unrestricted license.
Experience
Minimum 2 years of clinical nursing experience.
Skills/Competencies
Previous experience in Utilization Management required.
Strong interpersonal skills and ability to adapt in a dynamic environment.
Proficient in computer operations and ability to learn new software and hardware systems.
Working Conditions
Requires long periods of sitting and computer work, occasional lifting, bending, and travel as needed.
Work From Home Requirements
Must provide and support own internet services.
Maintain uninterrupted internet connection during work hours.
Compensation And Benefits
Starting salary range of $45,000 - $70,000 USD, commensurate with experience.
Comprehensive benefits package including health insurance, retirement plans, and performance bonuses.
Additional benefits such as dental, vision, life insurance options, and generous paid time off.
Our Commitment
We are committed to fair compensation and creating an inclusive environment that values diversity.
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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