Utilization Management Nurse Reviewer

The Utilization Management Nurse Reviewer plays a crucial role in healthcare systems by ensuring that medical services are used efficiently and appropriately. They review medical records, treatment plans, and patient information to determine the necessity and appropriateness of medical procedures, tests, and treatments.

Utilization Management Nurse Reviewers collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and maintain quality care. Their responsibilities include assessing medical necessity, coordinating care, conducting utilization reviews, providing recommendations for care plans, and ensuring adherence to regulations and guidelines. This role requires strong clinical knowledge, critical thinking skills, communication abilities, and the ability to make informed decisions regarding patient care pathways.

MAJOR DUTIES & RESPONSIBILITIES

• Conduct assessments of medical services to validate their appropriateness using established criteria and guidelines, ensuring the medical necessity of treatments (e.g., CMS, Milliman Care Guidelines, InterQual, or health plan specific guidelines/criteria).
• Examine and evaluate patient records to verify the quality of patient care and the necessity of provided services.
• Offer clinical expertise and serve as a clinical reference for non-clinical staff members.
• Input and manage essential clinical details within various medical management platforms.
• Keep up-to-date with regulatory prerequisites (such as URAC) and state standards for utilization review.
• Apply clinical reasoning to determine the suitable evidence-based guidelines.
• Foster efficient and high-quality patient care by effectively communicating with management teams, physicians, and the Medical Director.

Requirements

• Proficient in both written and spoken communication.
• Capable of maintaining professional communication with physicians and clients.
• Skilled at handling multiple tasks and adjusting swiftly in a dynamic office setting.
• Possesses a keen organizational sense and pays close attention to details.
• Adept at resolving intricate and multifaceted problems.
• Experienced with Microsoft tools such as Word, Excel, PowerPoint, and Outlook.
• Background in medical or clinical practice through education, training, or professional engagement.
• Holds an unrestricted LVN/RN license from an accredited vocational nursing program (for LVNs) or a nursing degree from an accredited college (for RNs).

Additional Duties

• May provide oversight to the work of the team members.
• Continuously improves processes that help to facilitate better turnaround time, peer to peer success rates and lessens returned reports by clients for clarification purposes, ultimately resulting in higher client satisfaction.
• Responsible for the final approval on cases for release to the client.
• Will act as a liaison and coordinate quality issue reports along with all new reviewer reports with the VP of Clinical Operations.

EDUCATION/CREDENTIALS:

Licensed Practical/Vocational Nurse with an active and unrestricted license to practice.

JOB RELEVANT EXPERIENCE:

2 yrs minimum clinical nursing experience is required. One year of previous experience in Utilization Management is preferred.

JOB RELATED SKILLS/COMPETENCIES:

Demonstrate strong abilities in both spoken and written communication, along with effective interpersonal skills. Possess a proficient understanding of computer operations, particularly the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows. Show the capability to acquire new skills and competencies to address the evolving requirements of systems, software, and hardware.

WORKING CONDITIONS/PHYSICAL DEMANDS:

Any lifting, bending, traveling, etc. required to do the job duties listed above. Long periods of sitting and computer work.

WORK FROM HOME TECHNICAL REQUIREMENTS:

Supply and support their own internet services.

Maintaining an uninterrupted internet connection is a requirement of all work from home position.

Benefits

We offer generous Paid Time Off, excellent benefits package and a competitive salary. Apple equipment and media stipend is provided for remote work space. Come up to speed quickly with our strong training program! If you want to work in an exciting, fast-paced environment where you can provide meaningful contributions, then we encourage you to apply.

ABOUT DANE STREET:

A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful, astute forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers’ Compensation, Disability, Auto and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers and Pharmacy Benefit Managers. We provide customized Independent Medical Exam and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.