Utilization Review Nurse

Rising Medical Solutions, LLC; United States; Remote; USD 75,000 - 105,000; Full time

Benefits offered by this job

Flexible Time Off

Health/Dental/Vision Insurance

401k Matching

Career Growth Opportunities

Job summary

Rising Medical Solutions, LLC is seeking a Utilization Review Nurse to perform comprehensive UR activities and nurse summaries. The role requires an active RN license and clinical or UR/case management experience.

You will document, review records, and collaborate with clients and providers to ensure appropriate authorization decisions. The position is full-time (40 hours/week, M-F) and emphasizes accuracy, time management, and strong analytical skills in a fast-paced, healthcare-cost

Qualifications

• Active and unencumbered RN license in one or more states.
• 3–5 years of clinical practice experience or 2 years of case management/UR experience.
• Experience with Workers' Compensation, short-term/long-term disability, or liability claims.
• Strong analytical and communication skills.

Responsibilities

• Perform all aspects of the Utilization Review Process
• Review records and requests for UR via mail, email, fax, or phone
• Utilize evidence-based guidelines to determine authorization vs. peer/physician review
• Write nurse summaries on all UR files
• Document in Rising's database and client databases; send determination letters
• Establish collaborative relationships with clients, patients, employers, providers and attorneys
• Track status of UR activity to meet turnaround times
• Maintain organized files with clinical documentation
• Use good clinical judgment, listening, and assessment skills
• Respond to inquiries regarding case status
• Proficient in computer use and multiple software programs

Skills

RN license in multiple states

Clinical nursing experience

Case management / UR experience

Time management & organization

Education

Associate's or Bachelor's degree in Nursing

Tools

Microsoft Word

Excel

Outlook

Job description

Description

Rising Medical Solutions has an opening for a Utilization Review Nurse, and we want to hear from you! We're a bill review and cost containment company - so what does that mean? Basically we are trying to fix a very broken healthcare system by reducing the cost of healthcare claims through bill review, case management, and utilization review. Our mission is "To make lives better" and everyone here at Rising works hard to achieve this goal. So take a look at the job, let us know what you think, and let's start working towards a better future!

**This is a full-time position - 40 hours per week (Must work M-F each day).

Responsibilities

• Perform all aspects of the Utilization Review Process
• Review records and requests for UR, which may arrive via mail, e-mail, fax, or phone
• Utilize evidence-based guidelines to determine if authorization can be given versus having to send the file or for Peer or Physician Review
• Write nurse summaries on all UR files
• Document properly in Rising's database (and client data bases when appropriate), and send determination letters on each completed UR
• Establish collaborative relationships with clients, patients, employers, providers and attorneys
• Track ongoing status of all UR activity so that appropriate turn-around times are met
• Maintain organized files containing clinical documentation of interactions with all parties of every claim
• Utilize good clinical judgment, careful listening, and critical thinking and assessment skills
• Respond to various written and telephonic inquiries regarding status of case
• Must be proficient in the use of a computer, including the use of various software programs simultaneously

Requirements

• An Associate's or Bachelor's degree in Nursing
• Hold an active and unencumbered RN license in one or more states
• 3 to 5 years of clinical practice experience or 2 years of case management and/or UR experience
• More than one state license (a plus)
• Experience with Workers' Compensation, short-term or long-term disability, or liability claims
• The ability to set priorities and work both autonomously and as a team member
• Well-developed time-management, organization, and prioritization skills
• Excellent analytical skills
• Superb oral and written communication
• The ability to gather data, compile information, and prepare summary reports
• Strong interpersonal and conflict resolution skills
• Experience in a fast-paced, multi-faceted environment
• Demonstrated persistence and attention to detail
• General understanding of CPT and ICD-9/ICD-10 codes and Medicare guidelines
• Working knowledge of: Microsoft Word, Excel, and Outlook
• Ability to remain calm during stressful situations
• A customer-service mindset

Benefits

• Generous Flexible Time Off (take it when you need it!)
• Comprehensive benefit package including health/dental/vision insurance, profit sharing, and 401k matching
• Career Growth Opportunities - We often promote from within
• Professional Development Reimbursement Program (PDRP)
• You will be part of our new Elevate program designed to recognize and reward employees for their hard work
• Rising was named a Top Workplace in the healthcare industry for 2023! Check out our profile here: Working at Rising Medical Solutions | Top Workplaces
• We're on YouTube! Check out our culture at: http://www.youtube.com/user/RisingMedical
• Want to see more? Check out our: Facebook: https://www.facebook.com/RisingMedicalSolutions LinkedIn: http://www.linkedin.com/company/rising-medical-sol..