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Posted 2 months ago
Requirements and responsibilities
Job Title: RN-Utilization Review Nurse.
Position Type: 4 plus month with possible extension.
Onsite Flexibility: Remote.
Pay Range: $34.00/hr- $37.00/hr.
Responsible for the review and evaluation of clinical information and documentation.
Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required.
3 years of clinical experience required- Managed Care/Medicare experience preferred.
* Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations. Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
* Evaluates documentation/information to determine compliance with clinical policy, regulatory, and accreditation guidelines.
* Accurately applies review requirements to assure the case is reviewed by a practitioner with clinical expertise for the issue at hand.
* Commands a comprehensive knowledge of complex delegation arrangements, contracts, clinical criteria, benefit plan structure, regulatory requirements, company policy, and other processes required to support the review of clinical documentation/information.
* Proactively and consistently applies regulatory and accreditation standards to assure activities are reviewed and processed within established guidelines.
* Condenses complex information into a clear and precise clinical picture while working independently.
* Reports audit or clinical findings to appropriate staff or others to ensure appropriate outcomes and/or follow-up for improvement as indicated.
M-F 8-5.
Monday - Friday 8am- 5pm EST.
Minimum of an associated degree in nursing.
Optionally, you can add more information later (benefits, pre-screening questions, etc.)