Utilization Review Nurse

Roles and Responsibilities

• Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions. Presents recommendations based on clinical review, criteria, and organizational policies to physician reviewers for final determination.
• Conducts prior authorization, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of care by applying MCG guidelines, medical policy, and benefit structure for defined service requests.
• Monitors clinical quality concerns, make referrals appropriately, identify and escalate care quality issues, and quickly identifies outlier cases, long length of stay cases or complicated prior authorization requests.
• Ability to interact with external facility or providers as needed to gather clinical information to support the medical necessity review process and plan of care.
• Assists departmental staff with issues related to coding, medical records/documentation, pre-certification, reimbursement, and claim denials/appeals.
• Employ active listening & motivational interviewing skills, and can handle difficult calls tactfully, courteously, professionally and document accordingly that can build patient trust and engagement.
• Effectively assess and facilitate appropriate utilization of clinical programs and/or discharge planning by thoroughly assessing and screening for proper care coordination following discharge.
• Effectively manages escalations within the department by ensuring appropriate accountability, sense of urgency, communication and follow through to closure.
• Ability to assist and facilitate working relationship with Medical Director on CM and UM cases.
• Demonstrates personal responsibility and accountability by meeting attendance and schedule adherence expectations with positivity, enthusiasm, and helpful personality.
• Ability to effectively excel in a virtual work environment through active participation in team huddles, Supervisor 1:1s, Instant Messaging, or check-ins, efficiently answering and documenting member/provider calls.

Experience and Skills Desired

• Previous healthcare/managed care appeals experience.
• Must have a current, unrestricted Texas nursing license or Compact License. Please include your license number(s) and the corresponding state(s) in your resume.
• Diploma from an accredited school/college of nursing required.
• You have 1-2 years of experience working at a health plan performing utilization management using standard practice guidelines.
• You have working knowledge of medical and insurance industry terminology including basic level CPT/ICD10, authorizations, digital health programs, NCQA/URAC standards.
• You have 3-5 years of clinical experience in a hospital or ambulatory setting assisting with direct patient care.
• You have a passion for quality, teamwork, problem solving, and critical thinking.
• You can work independently and comfortable in a fast-paced, deadline-oriented, tech savy, work environment.
• You have an area of interest or experience within cardiology/pulmonology, women’s health, orthopedic surgery/physical medicine, primary care/pediatrics, and oncology.
• You have experience outreaching and educating members telephonically.
• You have an innovative and entrepreneurial spirit with a passion to contribute to a much-needed change in our health care system.
• Bonus: Familiarity with Salesforce/Healthcloud/CareIQ.
• Bonus: CCM or ACM certification, MCG certification
• Bonus: Appeals experience

Telecommuting Requirements

• This is a remote position. Our whole company works remotely. Company headquarters are in Dallas, Texas.
• Company business hours are weekdays 9-5 CST. We will only consider candidates in the United States who reside in the CST or EST time zones. This position requires work during the stated business hours as well as rotating on-call weekends for utilization review cases.
• Required to have a dedicated work area established that is separate from other living areas and provides information privacy.
• Ability to keep all company sensitive documents secure.
• Must live in a location that receives an existing high-speed internet connection/service.

Benefits Package

• Competitive salary
• Comprehensive health, dental, and vision insurance as well as life and disability
• Retirement savings plan with company match
• Generous time off/vacation
• Professional development opportunities
• Flexible and remote work environment