Utilization Review Nurse (Contractor)--Retro Review *REMOTE*

Job Summary:

The RN Nurse Reviewer utilizes medical knowledge, established clinical guidelines, and physician support to provide medical review of care that is planned, unplanned or rendered to patients by providers and determine if care provided is medically necessary and appropriate.

Essential Duties and Responsibilities:

Applies medical criteria guidelines to evaluate for purposes of certification of outpatient surgical procedures, selected diagnostic procedures, home health services, therapy, and durable medical equipment.

· Comprehends current accepted treatment modalities for the wide range of medical/surgical and psychiatric disorders.

Reviews and determines if services requested are covered by the Plan.

· Participates in continuing nursing and medical education classes to assist in understanding new treatment concepts and their incorporation into current practice.

· Examines retro review certification requests for inpatient admissions, outpatient surgery, diagnostic procedures, therapy, home health, and durable medical equipment.

· Uses the computer to document and assess clinical data necessary for Utilization Review.

· Communicates with various levels of the provider system in our service area regarding Utilization Review issues.

· Reviews medical information from various facilities for medical necessity.

· Communicates with hospitals, physicians and subscribers regarding certification of hospital admissions and outpatient services.

Coordinates referral of cases to the Physician Reviewers; prepares cases that require review by the Physician Reviewers.

Prepares final letters dictated by the Physician Reviewer regarding the review of specific cases.

· Updates the Physician Reviewers on current medical review activity changes.

· Performs other duties and projects at the direction of Management in order to enhance the overall efficiency, effectiveness and productivity of the areas and their roles in the corporate goals.

· Participates in medical management review process to ensure success of the QM program and to provide quality reviews and cases.

· Performs to the highest level of professionalism, customer service and quality reviews.

· Works standard set of days and hours as agreed upon with Management.

Education and/or Experience:

· College degree or nursing diploma.

· Current RN licensure in state of nursing review.

· 3+ years clinical experience in a medical/surgical setting.

· 3+ years experience performing Utilization Review / utilization management

· 1+ years experience in a managed care setting.

Knowledge and skills:

· Knowledge of Information Technology system.

· Able to work with minimal supervision as a member in a team environment.

· Able to assess potential problems and formulate a solution either independently or with assistance of supervisor.

· Strong written, verbal, and interpersonal communication skills.

· Able to follow the Policy and Procedure guidelines developed by AMCM for the purposes of Utilization Review, quality management, and in compliance with URAC standards.

Physical Demands: Lifting up to 25lbs on occasion.

Work Environment:

· Office

Job Type: Contract

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Experience:

• Utilization review: 3 years (Required)

License/Certification:

• RN (Required)

Work Location: Remote