Utilization Review Nurse

Leave Your Mark; United States; On-site; USD 70,000 - 90,000; Full time

Job summary

A healthcare organization is seeking a Utilization Review Nurse to perform clinical reviews and determine the medical necessity of requested services. The ideal candidate will hold an RN license for NY and have clinical experience. Responsibilities include maintaining accurate records and providing exceptional customer service. This full-time position offers a chance to positively impact patient care within the healthcare system.

Qualifications

• Current, active and unrestricted RN license for the state of NY is required.
• 2 years of clinical experience as an RN in a varied clinical setting.
• Experience following established medical guidelines.

Responsibilities

• Perform clinical review to determine the medical necessity of requested services.
• Consult with Associate Medical Director and/or Medical Director for requests that do not meet criteria.
• Provide high quality, professional utilization management services.

Skills

RN clinical experience

Critical thinking

Time management

Proficient PC skills

Customer service

Education

Associates degree in Nursing

Bachelor's degree

Tools

MS Office

Job description

Overview

The Utilization Review Nurse (URN) performs clinical review to determine the medical necessity of requested services. The URN obtains clinical information and utilizes applicable clinical criteria to determine medical necessity, and when necessary, will consult with the Associate Medical Director and/or Medical Director for all requests that do not meet criteria for the client's policy. The URN will adhere to regulatory and compliance requirements, department productivity and quality metrics and provide exceptional customer service to all internal and external customers.

In this role, you will

• Provide high quality, professional utilization management services: medical necessity review for prior authorization, pre-certification, concurrent, as well as pre-claim or retrospective payment review.


• Maintain accurate records.


• Provide technical and professional expertise by demonstrating accurate understanding of regulatory and contractual issues for all employer/member groups.

Qualifications

• Associates degree in Nursing required. Bachelor\'s degree preferred. Current, active and unrestricted RN license for the state of NY is required.


• 2 years of clinical experience as an RN in a varied clinical setting required.


• Previous experience in a managed care setting preferred.


• Experience following established medical guidelines required.


• Clinical knowledge of the health or social work needs for the population served.


• Demonstrated ability to identify barriers to a successful care management path.


• Ability to interact effectively and professionally with internal and external customers.


• Proficient PC navigational skills required. Solid data entry and MS Office skills required.


• Excellent critical thinking and time management skills.

Seniority level

• Associate

Employment type

• Full-time

Job function

• Health Care Provider

Industries

• Hospitals and Health Care