Utilization Review Nurse

Jobtailor; Deutschland; Vor Ort; EUR 42.000 - 64.000; Vollzeit

Zusammenfassung

Jobtailor in Germany is seeking an experienced Registered Nurse to lead utilization management reviews, ensuring medical necessity and adherence to payer criteria. You will collaborate with physicians and case managers to evaluate inpatient and service requests.

The role requires strong analytical skills, clinical experience, and proficiency with MS Office and UM systems. You will document reviews, participate in meetings, and identify process improvements to support safe, cost-effective patient

Qualifikationen

• Current, unrestricted RN license (State license required).
• Minimum 3 years of clinical nursing experience.
• Minimum 1 year of Utilization Management (UM) or Utilization Review (UR) experience.
• Strong analytical, critical thinking, and problem-solving skills.
• Proficiency in Microsoft Office Suite (Excel, Word, Outlook) and familiarity with utilization management systems.
• Excellent verbal and written communication skills
• Strong organizational and time management skills

Aufgaben

• Perform utilization and concurrent reviews of inpatient cases using Milliman, Aetna, and BCBS criteria.
• Conduct medical necessity reviews for services requiring prior authorization, applying utilization-specific criteria.
• Request and evaluate clinical information needed to review requested services.
• Discuss cases and determinations with healthcare professionals and physician reviewers.
• Identify cases requiring intervention and collaborate with Case Managers as needed.
• Maintain appropriate and accurate documentation, ensuring compliance with audit standards.
• Participate in team meetings, educational sessions, and related activities.
• Review medical claims and pre‑determinations for medical necessity and appropriateness.
• Identify opportunities for process improvement and enhance communication among departments.
• Consult with Physician Reviewers for complex or challenging cases.

Kenntnisse

Analytical thinking

Problem-solving

Verbal communication

Written communication

Organizational skills

Time management

MS Office proficiency

UM systems familiarity

Ausbildung

RN license (state)

Tools

Microsoft Office

Utilization management systems

Jobbeschreibung

Responsibilities

• Perform utilization and concurrent reviews of inpatient cases using Milliman, Aetna, and BCBS criteria.
• Conduct medical necessity reviews for services requiring prior authorization, applying utilization-specific criteria.
• Request and evaluate clinical information needed to review requested services.
• Discuss cases and determinations with healthcare professionals and physician reviewers.
• Identify cases requiring intervention and collaborate with Case Managers as needed.
• Maintain appropriate and accurate documentation, ensuring compliance with audit standards.
• Participate in team meetings, educational sessions, and related activities.
• Review medical claims and pre‑determinations for medical necessity and appropriateness.
• Identify opportunities for process improvement and enhance communication among departments.
• Consult with Physician Reviewers for complex or challenging cases.

Requirements

• Current, unrestricted RN license (State license required).
• Minimum 3 years of clinical nursing experience.
• Minimum 1 year of Utilization Management (UM) or Utilization Review (UR) experience.
• Strong analytical, critical thinking, and problem-solving skills.
• Proficiency in Microsoft Office Suite (Excel, Word, Outlook) and familiarity with utilization management systems.
• Excellent verbal and written communication skills, with the ability to interact effectively with internal and external stakeholders.
• Strong organizational and time management skills, with the ability to handle multiple priorities independently.