Utilization Review Nurse Auditor

ExamWorks; United States; Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical, vision, dental benefits

Paid time off

401k

Job summary

ExamWorks is seeking a Utilization Review Nurse Auditor for a 100% remote role. The position requires a nursing license and 3–5 years of direct patient care.

You will perform quality utilization reviews, determine medical necessity, and ensure timely determination letters in compliance with URAC and federal/state guidelines. The role emphasizes collaboration with providers, accurate documentation, and adherence to client contracts.

Qualifications

• Active unencumbered RN, LPN or LVN required.
• Strong knowledge of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values.
• Experience in utilization management preferred.

Responsibilities

• Perform quality utilization review using evidentiary guidelines for peer review reports and addendums.
• Work with providers to identify level, intensity and duration of care.
• Document findings and evaluate medical necessity for care frequency and length.
• Ensure reviews meet URAC and regulatory turnaround times.
• Maintain URAC knowledge and regulatory compliance.
• Maintain accurate utilization review records in the database.
• Direct customer service to ensure timely delivery of determination letters.

Skills

RN/LPN/LVN

Healthcare terminology

Medical terminology

Analytical skills

Education

Nursing degree

High school diploma

Job description

ExamWorks is looking for a Utilization Review Nurse Auditor to join their team!

The Utilization Review Nurse Auditor is responsible for performing quality utilization review services and approving care that is medically necessary and appropriate according to evidenced based guidelines and criteria. This position ensures reports are completed with the highest quality and integrity and that all work is in full compliance with client contractual agreements, regulatory agency standards and/or federal and state mandates.
The position is 100% remote with a schedule ofMonday through Friday: 8:00am-5:00pm EST

• Perform quality utilization review through the use of acquired knowledge and application of evidenced based guidelines for peer review reports, correspondences, addendums and/or supplemental reviews.

• Work directly with providers to identify level, intensity and duration of care.

• Document findings, continue to evaluate medical necessity for frequency, intensity and length of required care.

• Assure that the consistency and quality of reviews meets or exceeds industry standards.

• Work to ensure quality reviews are completed within the required client, federal and state or URAC mandated turnaround times.

• Maintain and apply knowledge of URAC and other state and federal regulatory requirements.

• Maintain accurate record of Utilization Reviews within the appropriate database.

• Direct Customer Service Representatives to ensure timely delivery of determination letters.

• Assist in resolution of client complaints and/or quality assurance issues as needed.

• Ensure all quality assurance standards and federal ERISA, URAC, and/or other state guidelines are adhered to at all times.

• Provide insight and direction to management on any compliance concerns regarding products, company policies and procedures and/or client specifications.

• Participate in company meetings, training activities and continuing education requirements.

• Perform all other duties as assigned.

• High school diploma or equivalent required.

• Must be a graduate of an accredited nursing program; bachelor's degree preferred.

• Minimum of three to five years of direct professional patient care required.

• Experience in utilization management preferred.

• Active unencumbered Registered Nurse, Licensed Practical Nurse or Licensed Vocational Nurse required.

• Must have strong knowledge of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values.

• Must be a qualified typist with a minimum of 40 W.P.M.

• Must be able to operate a general computer, fax, copier, scanner, and telephone.

• Must be knowledgeable of multiple software programs, including but not limited to Microsoft Suite.

• Ability to follow instructions and respond to upper managements' directions accurately.

• Must demonstrate accuracy, thoroughness, and responsibility for quality of work, and ability to take initiative to identify improvements. Look for ways to improve and promote quality and monitors own work to ensure quality is met.

• Must be able to work independently, prioritize work activities and use time efficiently.

• Must be able to maintain confidentiality.

• Must be able to demonstrate and promote a positive team -oriented environment.

• Must be able to stay focused and concentrate with frequent interruptions and be able to work well under pressure and or stressful conditions.

• Must possess the ability to manage change, delays, or unexpected events appropriately.

• Ability to follow all company policies and procedures in effect at time of hire and as they may change or be added from time to time.

ExamWorks is a leading provider of innovative healthcare services including independent medical examinations, peer reviews, bill reviews, Medicare compliance, case management, record retrieval, document management and related services. Our clients include property and casualty insurance carriers, law firms, third-party claim administrators and government agencies that use independent services to confirm the veracity of claims by sick or injured individuals under automotive, disability, liability and workers' compensation insurance coverages.

ExamWorks, LLC is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.

Equal Opportunity Employer - Minorities/Females/Disabled/Veterans

ExamWorks offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.