Registered Nurse

ABCS, Inc. IT Executive and Contingent Workforce Staffing; United States; On-site; USD 45,460 - 46,838; Full time

Job summary

ABCS, Inc. is seeking a Utilization Management Nurse to perform clinical reviews for medical necessity, ensuring compliance within URAC standards. This contract position requires an active RN license and a minimum of four years of clinical nursing experience. Candidates will work collaboratively with healthcare providers to enhance care quality while managing cases efficiently.

Qualifications

• Four years clinical practice nursing experience in medical-surgical, surgical or critical care nursing.
• Ability to prioritize and make sound judgments.
• Proficiency in Microsoft Office applications.

Responsibilities

• Conducts and monitors clinical review to ensure medical necessity.
• Collaborates with healthcare providers to promote quality of care.
• Ensures compliance with URAC standards.

Skills

Critical thinking

Excellent verbal communication

Attention to detail

Education

Registered Nurse License

BSN preferred

Tools

Microsoft Office

Job description

5 days ago Be among the first 25 applicants

ABCS, Inc. IT Executive and Contingent Workforce Staffing provided pay range

This range is provided by ABCS, Inc. IT Executive and Contingent Workforce Staffing. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$33.00/hr - $34.00/hr

Position Type: (Contract to hire): Contract

Number of openings: 4

Position Length: ASAP to 12/31

Rate: $33/hr - $34/hr on W2, all inclusive

Key technologies: Internet Download speed—100 Mbps (confirming with IT), Camera on with Team, Holiday availability (Flexible hours), Reporting any issues to the leader ASAP, and maintaining communication.

Nice to have: Clinical review of prior approvals, network exceptions, benefit inquiries, inpatient medical/surgical admissions, outpatient procedures for providers, and/or other contracted lines of business. Organized, able to adjust to change/fast-paced environment

Number of Openings – 4

Job Profile Summary:

Utilization Management Nurse performs clinical review of prior approvals, network exceptions, benefit inquiries, inpatient medical/surgical admissions and outpatient procedures for providers, and/or other contracted lines of business. This role assesses and evaluates the efficiency and appropriateness of services for medical necessity through interpretation and review with evidenced-based criteria, clinical guidelines, corporate guidelines and policies and mandates and standards. Incumbent also facilitates and promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.

Responsibility

• Utilization Management: Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards. Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.

• Communication: Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.

• Compliance: Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.

• Workflow: Proactively and efficiently work incoming and outbound calls and/or queues from multiple sources within mandated requirements

• Knowledge: Remain current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.

• Other duties as assigned

Job Description

• Registered Nurse License, active and unencumbered state license in the state where job duties are performed is required. BSN preferred.

• Four (4) years of clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing.

• Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding

• Experience in utilization management and/or medical review preferred.

Specialized Knowledge & Skills

• Ability to prioritize and make sound nursing judgments through critical thinking

• Excellent verbal and written communication skills

• Ability to build collaborative relationships

• Attention to details

• Ability to interpret complex documentation

• Ability to work independently

Professional Certification or Licenses:

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Contract

Job function

• Job function

  Administrative and Management

• Industries

  Insurance

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