Remote Utilization Review Nurse - Case Management Pro

HealthEdge; United States; Remote; USD 55,000 - 61,000; Part time

Job summary

HealthEdge is seeking a highly motivated Utilization Review RN to join our team. The role involves prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service, and level of care, including handling appeals.

The position is remote in the US and is a contract role. Responsibilities include reviewing requests, coordinating discharge planning, analyzing care patterns,

Qualifications

• Registered Nurse with current unrestricted license.
• Certification in Case Management preferred.
• Minimum of 2 years’ clinical experience including acute care, discharge planning, case management, and utilization review.
• Minimum 1 year health insurance plan experience or managed care environment preferred.

Responsibilities

• Review, authorize and coordinate requests for elective, direct, ancillary, urgent, emergency, etc. services; contact appropriate personnel and consider alternatives.
• Analyze, research and prepare documentation for retrospective reviews and appeals per standards (local, state, federal, NCQA).
• Coordinate discharge planning needs and communicate with internal and external entities.
• Identify patterns of care related to disease progression and organize delivery.
• Research and resolve issues related to benefits, member eligibility and care coordination.
• Identify quality of care issues and route for resolution.
• Follow out-of-area or out-of-network services and advise on in-network transfers.
• Develop and deliver education for provider community on policies, procedures and benefits.

Skills

RN license

Case management

Clinical experience

Health insurance

Tools

Microsoft Office

Job description

HealthEdge is seeking a highly motivated Utilization Review RN to join our team. The role involves prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service, and level of care, including handling appeals.

The position is remote in the US and is a contract role. Responsibilities include reviewing requests, coordinating discharge planning, analyzing care patterns,