Utilization Review Nurse

1 week ago

Buffalo, United States Independent Health Full time

FIND YOUR FUTURE

We're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and commitment to diversity and inclusion.

Overview

The Utilization Review Nurse (URN) performs clinical review to determine the medical necessity of requested services. The URN obtains clinical information and utilizes Independent Health policy and/or applicable clinical criteria to determine medical necessity, and when necessary, will consult with the Associate Medical Director and/or Medical Director for all requests that do not meet criteria or Independent Health policy. The URN will adhere to regulatory and compliance requirements, department productivity and quality metrics and provide exceptional customer service to all internal and external customers.

Qualifications

* Associates Degree in Nursing required; Bachelor's degree preferred. Current, active, unrestricted, and licensed registered nurse (RN) required.
* Two (2) years of clinical experience as an RN in a varied clinical setting required.
* Previous utilization review experience preferred.
* Previous experience in a managed care setting preferred.
* Experience following established medical guidelines required.
* Clinical knowledge of the health or social work needs for the population served.
* Demonstrated ability to identify barriers to a successful care management path.
* Ability to interact effectively and professionally with internal and external customers.
* Proficient PC Navigational skills required; solid data entry and MS Office skills required.
* Excellent critical thinking and time management skills.
* Excellent written, verbal, and interpersonal communication skills, with demonstrated ability to provide exceptional customer service to internal and external customers.
* Demonstrated transferable knowledge, skill, and ability to complete job duties independently and proficiently. Flexibility in work schedules and assignments required.
* Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.

Essential Accountabilities

Provide High Quality, Professional Utilization Management Services: (Medical necessity review for prior authorization, pre-certification, concurrent, as well as pre-claim or retrospective payment review.)

* Prompt, courteous, professional and error free in performing utilization management functions.
* Available to answer inbound phone calls within required timeframes.
* Maintain quality of reviews and documentation by demonstrating sound judgment, excellent analytical and communications skills with attention to detail, utilizing designated criteria and/or Independent Health policy as required.
* Complete requests in compliance with designated turnaround time.

Maintain Accurate Records:

* Clear documentation of clinical information for medical necessity review of all requests, procedures, admissions, and concurrent review.
* Accurate documentation of criteria, Independent Health policy or AMD review in case notes.
* Complete and timely follow through for disposition of cases - MD reviews, chart reviews, audits, case management referrals, etc.

Provide Technical and Professional Expertise:

* Demonstrate accurate understanding of regulatory and contractual issues for all employer/member groups.
* Ability to ascertain and gather appropriate information for completion of inquiry (i.e. medical necessity).
* Maintain current level of knowledge of nursing, medical and health trend issues.
* Exhibits proactive approach to problem solving and critical thinking skills.
* Act as resource for professional information.

Immigration or work visa sponsorship will not be provided for this position

Hiring Compensation Range: $35.50 - $38.00 hourly

Compensation may vary based on factors including but not limited to skills, education, location and experience.

In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.

As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant's race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. Click here for additional EEO/AAP or Reasonable Accommodation information.

Current Associates must apply internally via the Job Hub app.

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