Remote Utilization Review RN — Contract

Wellframe; United States; Remote; USD 55,000 - 61,000; Full time

Job summary

HealthEdge is seeking a motivated Utilization Review RN to perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity and appropriate level of care. The role involves coordinating care across the health care continuum and may include care planning and member outreach.

The position requires an unrestricted RN license, at least 2 years of clinical experience, and familiarity with managed care.

Qualifications

• Registered Nurse with current unrestricted RN license.
• Certification in Case Management may be preferred.
• Minimum of 2 years’ clinical experience in care management or utilization review.
• Experience in health insurance plan or managed care is a plus.

Responsibilities

• Review, research and authorize requests for elective and urgent services using approved clinical protocols.
• Analyze retrospective reviews and appeals in line with NCQA standards.
• Coordinate discharge planning with internal and external entities.
• Identify and document quality of care issues and route for resolution.
• Support provider services with reimbursement discussions for non-contracted providers.

Skills

Communication skills

Customer service

Clinical criteria application

Care knowledge

Interpersonal skills

Education

RN license

Tools

Microsoft Office Suite

Job description

HealthEdge is seeking a motivated Utilization Review RN to perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity and appropriate level of care. The role involves coordinating care across the health care continuum and may include care planning and member outreach.

The position requires an unrestricted RN license, at least 2 years of clinical experience, and familiarity with managed care.