Utilization Review RN

Healthcare Support Staffing; Mason (OH); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Positive work environment

Job summary

A national healthcare staffing firm is seeking a dedicated Registered Nurse to manage utilization review processes. This RN will ensure quality and cost-effective healthcare by assessing medical necessity, coordinating care, and managing appeals for denied services. Candidates must hold a clear RN license in Ohio and have experience in acute care and medical record reviews. This role offers a competitive salary, benefits, and a supportive work environment.

Qualifications

• Clear and active RN license in the state of OH.
• At least an Associate's or Bachelor's degree in Nursing.
• Experience in acute clinical care and utilization management.

Responsibilities

• Ensure cost-effective care through medical necessity assessments.
• Coordinate care with facilities and providers.
• Manage appeals for denied services.
• May also manage appeals for services denied.
• Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.
• Facilitates member care transition through the healthcare continuum.
• Refs treatment plans/plan of care to clinical reviewers as required.

Skills

RN license

Clinical care experience

Utilization review

Medical record review

Education

AS/BS in Nursing

Job description

HealthCare Support Staffing, Inc. (HSS), is a proven industry-leading national healthcare recruiting and staffing firm. HSS has a proven history of placing talented healthcare professionals in clinical and non-clinical positions with some of the largest and most prestigious healthcare facilities including: Fortune 100 Health Plans, Mail Order Pharmacies, Medical Billing Centers, Hospitals, Laboratories, Surgery Centers, Private Practices, and many other healthcare facilities throughout the United States. HealthCare Support Staffing maintains strong relationships with top providers in healthcare and can assure healthcare professionals they will receive fast access to great career opportunities that best fit their expertise. Connect with one of our Professional Recruiting Consultants today to see how a conversation can turn into a long-lasting and rewarding career!

Job Description

Daily Responsibilities:

• Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting
• Applies clinical knowledge to work with facilities and providers for care coordination
• Works with medical directors in interpreting appropriateness of care and accurate claims payment
• May also manage appeals for services denied
• Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts
• Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract
• Facilitates member care transition through the healthcare continuum
• Refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications

Hours for this Position: Monday-Friday (40 hours/week)

Advantages of this Opportunity:

• Competitive salary, negotiable based on experience
• Benefits offered, Medical, Dental, and Vision
• Fun and positive work environment
• Weekly deposit options

Qualifications

Requirements:

• Must have clear and active RN license in the state of OH
• AS/BS in Nursing
• Experience in acute clinical care
• Experience with medical record review/utilization review/utilization management

Additional Information

Are you an experienced Registered Nurse with Utilization review experience looking for a new opportunity with a prestigious healthcare company? Do you want the chance to advance your career by joining a rapidly growing company? If you answered “yes" to any of these questions – this is the position for you!

Interested in hearing more about this great opportunity? Please click apply or call Amanda Hammer at 407-636-7030 ext.201 for additional details.