Utilization Review Nurse

Career Center; United States; Remote; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical/Dental/Vision insurance

Generous PTO and holidays

TeleDoc 24/7/365

Disability plans (short/long-term)

EAP

401K with company match

Referral bonus program

Job summary

American Health Plans, a division of American Health Partners Inc., seeks a Utilization Review Nurse to assess medical necessity and quality of care. You will support the Clinical Services Department and Medical Director, ensuring compliance with regulatory guidelines while coordinating care for plan members.

The role requires RN licensure with UR experience; CCM is a plus. The position offers comprehensive benefits and opportunities to collaborate with nurses and physicians across multiple

Qualifications

• At least 1 year in utilization management with a health plan or hospital UM department using Interqual or MCG
• Broad knowledge of Medicare regulations and guidance
• Trained in UR/URAC and NCQA principles and procedures
• Excellent customer service experience
• Strong medical terminology and CPT/ICD-10/HCPCS knowledge

Responsibilities

• Assess medical necessity, quality of care, and level of care for plan members
• Identify lowest-restriction placement settings based on medical necessity
• Coordinate with providers to gather clinical data
• Apply review criteria to determine medical necessity
• Certify cases meeting criteria and consult when needed
• Refer cases to internal teams (case management, medical) as appropriate
• Meet accreditation, contractual, and regulatory timeframes

Skills

Customer service

Communication

Critical thinking

Independent work

Education

RN license

CCM (preferred)

Job description

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Iowa, Idaho, Louisiana, and Indiana with planned expansion into other states in 2025. For more information, visit AmHealthPlans.com.

If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application!

Benefits and Perks include:

• Affordable Medical/Dental/Vision insurance options
• Generous paid time-off program and paid holidays for full time staff
• TeleDoc 24/7/365 access to doctors
• Optional short- and long-term disability plans
• Employee Assistance Plan (EAP)
• 401K retirement accounts with company match
• Employee Referral Bonus Program

JOB SUMMARY:

The Utilization Review Nurse is to assess the medical necessity and quality of healthcare services by conducting pre-service, concurrent, and retrospective utilization management reviews. The primary role of the Utilization Management (UM) Nurse is to provide clinical support to the Clinical Services Department and Medical Director to assure that members receive all appropriate medical services in compliance with medical and regulatory guidelines.

ESSENTIAL JOB DUTIES:

To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.

• Assess the medical necessity, quality of care, level of care and appropriateness of health care services for plan members
• Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity
• Conduct outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data
• Apply clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided
• Certify cases that meet clinical review criteria, guidelines and/or screens
• Consult with physician when reviews do not meet clinical review criteria, guidelines, and screens
• Refer cases to other professionals internally, including case management and medical consultation when indicated
• Adhere to accreditation, contractual and regulatory timeframes in performing all utilization management review processes
• Ensure that the Director of Medical Management or designee is made aware of any potential risk management issues in a timely manner
• Other duties as assigned

JOB REQUIREMENTS:

• Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility
• Encourage an atmosphere of optimism, warmth and interest in patients’ personal and health care needs
• Develop and maintain collaborative relationships with providers and educate on levels of care
• Ensure the integrity and high quality of utilization management services
• Self-motivated
• Ability to work independently and as part of a team
• Able to work congenially with a wide variety of individuals
• Maintain the highest level of confidentiality and professionalism at all times
• Strong oral and written communications skills, including active listening
• Proficient in navigating through multiple computer applications
• Positive, engaging customer service skills
• Critical thinking and decision-making skills
• Successful completion of required training
• Handle multiple priorities effectively
• Independent discretion/decision making
• Make decisions under pressure

REQUIRED QUALIFICATIONS:

• Experience:
  • At least 1 year experience in utilization management with a health plan or hospital-based UM department with use of Interqual or MCG
  • Prefer clinical experience
  • Broad knowledge of Medicare regulations and guidance
  • Trained in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures
  • Excellent customer service experience
  • Strong knowledge of medical terminology and CPT, ICD-10, and HCPCS codes
  • Proven ability to problem-solve and make solid decisions
• License/Certification:
  • Current Certified Case Manager (CCM) credential is a plus
  • Current, active and unrestricted Registered Nurse (RN) license

EQUAL OPPORTUNITY EMPLOYER

This Organization is an equal opportunity employer. We do not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. This Organization will make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. A key part of this policy is to provide equal employment opportunity regarding all terms and conditions of employment and in all aspects of a person's relationship with the Organization including recruitment, hiring, promotions, upgrading positions, conditions of employment, compensation, training, benefits, transfers, discipline, and termination of employment.