Utilization Review Nurse - Remote Minnesota

UTILIZATION REVIEW SPECIALIST - RN

Work Location: Work from home

Position Description

This position is responsible to evaluate member specific clinical information against objective, standardized criteria to determine medical necessity, appropriateness, and efficiency of specific services the organization has targeted for prior authorization. Identify care management needs and refer members to care management as appropriate.

• Complete the continuum of the Utilization Review processes within the established department turnaround times including: first level medical necessity review, consultation with Medical Directors and/or healthcare providers, and/or facilitate peer to peer discussions when applicable.
• Review medical records as part of prior authorization review for services and/or review of acute care admissions and concurrent length of stay review.
• Partner with healthcare providers to assess member’s discharge needs for post-acute care, actively participate to assist with transition of care, and to establish care support.
• Refer cases to Case Management for potential case management activities based on identified member needs or utilization specific concerns.
• Develop a comprehensive knowledge of member benefits for each product; understand, implement, and support the Evidence of Coverage, and follow organization policies as they relate to member benefits.
• Provide medical necessity review for published authorization strategies, medical policies, review criteria, review standards, and regulatory requirements in the application of the Utilization Review process.
• Understand and support the organization’s provider network and contracts.
• Document review activities in accordance with professional nursing and established organizational standards.
• Participate in Holiday On-Call Coverage.
• Participate in and pass Annual Regulatory Inter-Rater Reliability testing.
• Collaborate with claims, provider assistance center, and provider relations and contracting in ad hoc provider education.
• Participate in cross-departmental workgroups or teams as assigned.

Required Experience

• Registered Nurse, BSN preferred. Current and unrestricted Minnesota nursing license required.
• Two years acute care clinical experience or a minimum of 3-5 years’ experience in a post-acute care setting.

Preferred Experience

• Utilization review and/or case management.
• Knowledge of Utilization Review standards, decision making tools (ie: InterQual or MCG), and experience working with state and federally funded programs.
• Health Plan experience preferred.

Job Type: Contract

Pay: Up to $40.00 per hour

Benefits:

• 401(k)
• Paid time off

Schedule:

• Monday to Friday

Application Question(s):

• Do you have a current unrestricted MN nursing License?

Experience:

• Utilization review: 2 years (Required)

License/Certification:

• RN (Required)

Work Location: Remote