Utilization Review Nurse: Elevate Care Quality & Outcomes

TruHealth; Oregon; Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Medical/Dental/Vision insurance

Paid time-off and holidays

TeleDoc 24/7/365 access to doctors

Disability plans — short and long term

Employee Assistance Plan (EAP)

401K with company match

Employee 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 for plan members. You will support the Clinical Services Department and Medical Director in ensuring services comply with medical and regulatory guidelines.

Responsibilities include evaluating level of care, coordinating with providers, and applying criteria to certify or escalate cases. Requires RN license; CCM credential is a plus.

Qualifications

• 1+ year experience in utilization management in a health plan or hospital UR department; experience with InterQual or MCGo preferred.
• Broad knowledge of Medicare regulations and URAC/NCQA principles, policies, and procedures.
• Current RN license required; CCM credential is a plus.

Responsibilities

• Assess medical necessity, quality of care, level of care and appropriateness of services for plan members.
• Identify least restrictive placement settings based on medical necessity.
• Reach out to requesting providers to gather clinical data from specialists, ancillary providers and institutions.
• Apply review criteria and certify cases that meet criteria.
• Consult with physician when reviews do not meet criteria.
• Refer cases to internal teams when indicated and adhere to regulatory timeframes.
• Notify Director of Medical Management or designee of potential risk issues in a timely manner.
• Perform other duties as assigned.

Skills

Customer service

Medical terminology

Problem solving

Communication

Education

RN license

Certified Case Manager (CCM) credential

Tools

InterQual

MCGo

Job description

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

Responsibilities include evaluating level of care, coordinating with providers, and applying criteria to certify or escalate cases. Requires RN license; CCM credential is a plus.