Utilization Review Nurse

Integrated Resources, Inc ( IRI ); Illinois; Remote; USD 70,000 - 100,000; Full time

Job summary

A health care recruitment agency is seeking a Recruitment Manager to assess and analyze clinical service requests, verify member benefits, and process prior authorizations. Candidates must have an Illinois state RN license and 1-3 years of experience in hospital or medical clinic settings. This is a fully remote position, offering work within a collaborative multidisciplinary team. The role focuses on ensuring compliance with regulations and providing optimal member care.

Qualifications

• Candidates must have an Illinois state RN license.
• 1-3 years of experience in hospital or medical clinic, utilization review or prior authorization.

Responsibilities

• Assess and analyze clinical service requests using evidence-based criteria.
• Verify member benefits and eligibility.
• Process prior authorization determinations within regulatory timelines.
• Collaborate with multidisciplinary teams.
• Provide daily review and evaluation of members requiring hospitalization and/or procedures with prior authorizations.
• Provide concurrent review and prior authorizations as needed.

Skills

Utilization review

Prior authorization

Evidence-based criteria

Tools

MCP/MCG criteria

Job description

Recruitment Manager @ Integrated Resources, Inc | Human Resources Management

Location: 100% Remote

Schedule: M-F 9:00am to 5:30pm with rotating Saturdays from 7-11am CST, including holiday rotation

Job Description

• This position is fully remote, but candidates need to have an Illinois state RN license
• Assess and analyze clinical service requests (e.g., surgeries, outpatient therapies, DME) using evidence-based MCP/MCG criteria.
• Verify member benefits and eligibility
• Process prior authorization determinations within regulatory timelines
• Collaborate with multidisciplinary teams

Summary

• Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing clients' members with the right care at the right place at the right time.
• Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for Client Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Provides concurrent review and prior authorizations (as needed) according to Client policy for Client members as part of the Utilization Management team.
• Consults with and refers cases to Client medical directors regularly, as necessary. Complies with required workplace safety standards.

Required License/Certification

• Active, unrestricted IL State Registered Nursing (RN) license in good standing.

Required Years of Experience

• 1-3 years of hospital or medical clinic, utilization review or prior authorization experience

Seniority level

Associate

Employment type

Contract

Job function

Health Care Provider

Industries

Hospitals and Health Care and Public Health