Registered Nurse Utilization Review

APN Consulting Inc; Nova Iguaçu; Teletrabalho; BRL 80.000 - 120.000; Tempo integral

Resumo da oferta

A leading company is seeking a UM Nurse to promote quality care and cost-effective outcomes through collaboration and coordination. The role involves conducting medical necessity reviews, ensuring discharge planning, and advocating for member needs. Candidates should have an Associate's degree in nursing and at least 2 years of experience in medical management.

Qualificações

• Minimum of 2 years experience in medical management clinical functions.
• Working knowledge of MCG, InterQual, and NCQA standards preferred.

Responsabilidades

• Perform medical necessity reviews for assigned members.
• Collaborate with Medical Director on adverse determination notices.
• Ensure timely discharge planning and communication.

Conhecimentos

Collaboration

Patient-centered care

Medical necessity reviews

Discharge planning

Formação académica

Associate's degree in nursing

Descrição da oferta de emprego

Location: Remote

Shift Type: 8am – 5pm PDT

Workdays / Hours: Including evening, weekend, and holiday coverage

Contract Duration: 3 Months (Temp to Perm Possibility)

Overview:

The UM Nurse promotes quality and cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring intervention efficacy, and advocating for necessary services and resources. The role involves providing patient-centered care across the continuum.

Role and Responsibilities:

• Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members.
• Review cases for medical necessity using clinical criteria such as Medicare, Medicaid, InterQual, Milliman, or specific health plan guidelines.
• Collaborate with the Medical Director to ensure the integrity of adverse determination notices according to quality standards.
• Ensure timely and appropriate discharge planning and communication with transition of care teams.
• Meet or exceed productivity targets.
• Serve as a resource to non-clinical team members when applicable.

Qualifications and Education Requirements:

• Associate's degree in nursing preferred.
• Minimum of 2 years experience in medical management clinical functions.

Working knowledge of MCG, InterQual, and NCQA standards is preferred.