Remote Registered Nurse RN Concurrent UM Review – Compact License, Multiple Locations

✨ About The Role

- Responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency - Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination - Conducts utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines - Answers Utilization Management directed telephone calls in a professional and competent manner - Refers cases to a review physician when treatment requests do not meet necessity per guidelines - Documents all utilization review activities and outcomes, including calls made and received, demographic and service group information - May provide guidance and coaching to other utilization review nurses and participate in their orientation - Identifies and refers potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to the Compliance Department - Conducts rate negotiation with non-network providers and documents rate negotiation accurately for proper claims adjudication

⚡ Requirements

- Current, unrestricted RN license or compact license required - 2+ years of experience in managed care OR 5+ years nursing experience preferred - Proficient in PC software computer skills - Experience with authorization, telephonic or telecommute work, utilization review or management, ICD-10, CPT coding, InterQual or Milliman criteria - Proven problem-solving and analytical skills - Excellent communication skills, both verbal and written - Ability to interact productively with individuals and multidisciplinary teams with minimal guidance - Strong planning, organizing, conflict resolution, negotiating, and essential interpersonal skills