Utilization Review Nurse

Santa Barbara Cottage Hospital; United States; Remote; USD 65,000 - 90,000; Full time

Job summary

A prominent healthcare provider is seeking a Utilization Review Nurse responsible for assessing medical necessity for outpatient services. The role requires a licensed RN or LPN with 2-3 years of clinical experience, focusing on compliance and efficient communication with medical staff and clients.

Qualifications

• Minimum 2-3 years of varied clinical experience required.
• Managed care experience preferred.
• Excellent oral and written communication skills.

Responsibilities

• Conducts medical necessity reviews for outpatient services.
• Evaluates severity of illness and service intensity during inpatient admissions.
• Ensures compliance with state and federal regulations.

Skills

Communication

Customer Service

Analytical Skills

InterQual Experience

Education

Licensed RN or LPN

Clinical Experience

Tools

MS Office

Job description

COMPANY OVERVIEW:

HealthAxis is a prominent provider of core administrative processing system (CAPS) technology, business process as a service (BPaaS), and business process outsourcing (BPO) capabilities to healthcare payers, risk-bearing providers, and third-party administrators. We are transforming the way healthcare is administered by providing innovative technology and services that uniquely solve critical healthcare payer challenges negatively impacting member and provider experiences.

We live and work with purpose, care about others, act with integrity, communicate with transparency, and don’t take ourselves too seriously.

We're not just about business – we're about people. Our commitment to a people-first approach shapes everything we do, from collaborating as a team to serving our valued clients. We believe that creating a vibrant and human-centric environment can inspire engagement, empower our team members, and ignite a sense of purpose in all that we accomplish.

PURPOSE AND SCOPE:

The Utilization Review Nurse is responsible for the medical necessity review of outpatient services that require prior authorization, and/or management of concurrent inpatient admissions. The medical necessity review process includes assessment and interpretation of plan specific benefits, medical criteria, and clinical documentation.

PRINCIPAL RESPONSIBILITIES AND DUTIES:

• Performs prospective, concurrent, and retrospective inpatient and/or outpatient utilization reviews (UR) using evidence-based guidelines, policies and nationally recognized clinical criteria, and internal policies and procedures.

• Evaluates severity of illness and intensity of service of member’s needs at time of inpatient admission utilizing approved criteria.

• Triage and prioritize cases and other assigned duties to meet CMS turnaround time standards.

• Prepare and escalate cases to MDs for review when appropriate.

• Demonstrates effective communication methods and skills, using lines of authority appropriately.

• Establishes a relationship with providers to determine/provide needed services to member.

• Maintains accurate record of UR activities.

• Regular attendance is required as employee works as part of a team & requires interaction with medical staff and clients.

• Adheres to quality standards and confidentiality policies and procedures.

• Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.

• Adapts to changes in policies, procedures, new techniques, and additional responsibilities.

CUSTOMER SERVICE:

• Responsible for driving the HealthAxis culture through values and customer service standards.

• Accountable for outstanding customer service to all external and internal contacts.

• Develops and maintains positive relationships through effective and timely communication.

• Takes initiative and action to respond, resolve and follow up regarding customer service issues with all customers in a timely manner.

EDUCATION, EXPERIENCE AND REQUIRED SKILLS:

• Licensed RN or LPN required.

• Minimum of two to three years varied clinical experience required.

• Managed care experience preferred.

• An equivalent combination of education, training, and experience.

• Ability to read and interpret documents and calculate figures and amounts.

• Excellent oral and written communication skills including good grammar, voice and diction.

• Proficient in MS Office with basic computer and keyboarding skills.

• Excellent customer service skills (friendly, courteous and helpful).

• InterQual experience helpful.