** M-F 8:00 - 4:30 PM **NO WEEKENDS**
*** Full-Time, Benefits Available, CONTRACT position, expected to last 3-6 months, or longer! ***
Utilization Review Nurse Job Summary:
- The Utilization Review Nurse is responsible for utilization management or prior-authorized treatments, and the utilization review of concurrent patient treatment.
- The Utilization Review Nurse will performs reviews of services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
- Utilize clinical skills to provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
- The Utilization Review Nurse will obtain the information necessary to assess a patient's clinical condition, identify ongoing clinical care needs and ensure that patients receive services in the most optimal setting to effectively meet their needs.
- Current, valid, and unrestricted state Registered Nurse (R.N.) license.
- CCM or CPUR/CPUM/CPHM or similar certification is preferred
- Roughly 3-5 years acute care clinical nursing experience is required.
- Around 2-3 years of acute care hospital case management, utilization review, or appeals experience.
- Must have strong skills in medical assessment / medical record review; knowledge of coding a plus.
- Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
- Experience using MCG criteria for medical necessity, setting and level of care, and concurrent patient management.
- Computer skills to include Microsoft Word, Excel, database use, and basic data entry.