Remote Utilization Review Nurse

TriWest Healthcare Alliance; Phoenix (AZ); Remote; USD 88,000 - 98,000; Full time

Job summary

TriWest Healthcare Alliance seeks a Utilization Management Clinical Review nurse to evaluate and authorize beneficiary care, focusing on cost-effective, appropriate utilization of Behavioral Health and Medical/Surgical services.

Responsibilities include preauthorization, inpatient and continued stay reviews, and presenting complex cases for Medical Director review, while staying compliant with InterQual and TriWest policies.

Qualifications

• Active, unrestricted RN license.
• U.S. Citizenship.
• Must be able to obtain favorable DoD background investigation.
• 2+ years clinical experience.
• 2+ years UM experience.
• Proficient with Word, Excel, Outlook.

Responsibilities

• Conducts prior authorization and continuation of stay activities.
• Assesses medical necessity using InterQual Criteria and Behavioral Health criteria.
• Determines alignment with TriWest benefit program and notifies facilities.
• Maintains timely reviews and communicates with providers and beneficiaries.
• Refers cases to Case Management or Disease Management when appropriate.
• Ensures compliance with federal, state, and accreditation standards.

Skills

Verbal & written communication

MS Office proficiency

InterQual clinical guidelines

Team coordination

Education

Active RN license

U.S. Citizenship

Tools

Microsoft Office Suite

Job description

TriWest Healthcare Alliance seeks a Utilization Management Clinical Review nurse to evaluate and authorize beneficiary care, focusing on cost-effective, appropriate utilization of Behavioral Health and Medical/Surgical services.

Responsibilities include preauthorization, inpatient and continued stay reviews, and presenting complex cases for Medical Director review, while staying compliant with InterQual and TriWest policies.