Utilization Review Nurse

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 an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
• Associate Degree in Nursing or graduation from an accredited school of nursing OR successful completion of a Nursing Diploma Program in an accredited school of nursing
• Ability to obtain additional state licenses to meet business needs
• 1+ year of utilization review experience in a managed care setting
• Strong experience utilizing MCG (Milliman Care Guidelines) or InterQual
• 1+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital)
• Weekend availability is required; all applicants must be able to work at least one weekend day (Saturday or Sunday) each week

Bonus Points:

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