Utilization Review Nurse

About the role:

You will perform frequent case reviews, check medical records and speak with care providers regarding treatment as needed. You will make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions.

You will report into the Supervisor, Utilization Review.

Responsibilities:

• Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines
• Obtain the information necessary (via telephone and fax) to assess a member's clinical condition, and apply the appropriate evidence-based guidelines
• Meet required decision-making SLAs
• Refer members for further care engagement when needed
• Compliance with all applicable laws and regulations
• Other duties as assigned

Requirements:

• Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
• Associate Degree or Bachelors Degree - Nursing or Graduate of Accredited School of Nursing
• MCG or InterQual tooling experience
• Ability to obtain additional state licenses to meet business needs
• 1+ year of utilization review experience in a managed care setting
• 1+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital)

Bonus points:

• BSN
• Previous experience conducting concurrent or inpatient reviews for a managed care plan