Utilization Review Nurse

SPECTRAFORCE; California (MO); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare company is seeking a Registered Nurse III for a remote position in California. This role involves performing concurrent reviews for inpatient admissions and ensuring compliance with regulatory standards. The ideal candidate will have 3-5 years of acute care experience and an active California RN license.

Qualifications

• Minimum 3-5 years Acute Care Experience required.
• Must be a Registered Nurse in CA with an Active Unrestricted License.
• Previous experience in prior authorization or utilization management preferred.

Responsibilities

• Perform concurrent reviews for inpatient admissions using evidence-based guidelines.
• Triages and prioritizes cases to meet required regulatory turn-around times.
• Communicate determinations to providers in compliance with regulations.

Skills

Computer Skills

Communication Skills

Education

AS Degree Nursing

BSN preferred

Tools

Microsoft Office

Windows-based programs

Job description

Direct message the job poster from SPECTRAFORCE

Position Title: Registered Nurse III (Concurrent Review Nurse)

Work Location: Remote in California

Assignment Duration: 6+ months

Work Arrangement: Remote

Position Summary: Performs concurrent reviews for inpatient admissions using evidence-based guidelines, policies, and clinical criteria across lines of business. Ensures compliance with regulatory and accreditation standards.

Key Responsibilities:

• Performs concurrent reviews for inpatient admissions for members using FEP and BSC evidenced based guidelines, policies and nationally recognized clinal criteria across FEP’s line of business.
• Triages and prioritizes cases to meet required, regulatory turn-around times.
• Expedites access to appropriate care for members with urgent needs using expedited review process.
• If the recommendation is to deny a specific treatment, presents cases to Medical Director (MD) as required.
• Communicate determinations to providers and/or members to be in compliance with state, federal and accreditation requirements.
• Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
• Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
• Identifies potential Third Party Liability and Coordination of Benefit cases and notifies appropriate internal departments.
• Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
• Provides referrals to Case Management, Disease Management.
• Qualification & Experience:
• Minimum 3-5 years Acute Care Experience.
• Strong Computer Skills related to Windows-based programs and applications.
• Good Communication Skills.
• Must be a Registered Nurse in the State of CA, with an Active Unrestricted License.
• AS Degree Nursing, BSN preferred.
• Proficient with windows-based programs, outlook, Microsoft office.
• Proficient in navigating multiple windows and screens.
• Active unrestricted California Registered Nurse.
• Varied clinical background (preferred).
• Previous experience in prior authorization or utilization management preferred.
• Big gaps in employment; must reside in California (disqualifiers).
• For information on benefits, equal opportunity employment, and location-specific applicant notices, click here

At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position's starting pay is: $40.00/hr

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Contract

Job function

• Job function

  Other

• Industries

  Hospitals and Health Care and Hospitals

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