Utilization Review Nurse
4 weeks ago
OverviewTitle: Clinical Review Nurse – Prior Authorization ReviewLocation: Fully Remote (PST Time Zone - WA/OR Resident)Duration: 12-Month (Potential for Extension)About the RoleWe are seeking an experienced Clinical Review Nurse for Prior Authorization Review to join our Utilization Management team. In this role, you will conduct concurrent and prior authorization reviews, ensure timely discharges, and collaborate with medical directors, providers, and care management teams to support high-quality, cost-effective care for members.Key ResponsibilitiesPerforms medical necessity and clinical reviews of authorization requests to determine the medical appropriateness of care in accordance with regulatory guidelines and criteriaWorks with healthcare providers and the authorization team to ensure timely review of services and/or requests to ensure members receive authorized careCoordinates as appropriate with healthcare providers and interdepartmental teams, to assess the medical necessity of care of memberEscalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of careAssists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilitiesCollects, documents, and maintains all members’ clinical information in health management systems to ensure compliance with regulatory guidelinesAssists with providing education to providers and/or interdepartmental teams on utilization processes to promote high-quality and cost-effective medical care to membersProvides feedback on opportunities to improve the authorization review process for membersPerforms other duties as assignedQualificationsActive RN license (WA; must be in good standing)2–4 years of Prior Authorization review and InterQual experience requiredStrong documentation and communication skillsAbility to work in a high-volume environment while maintaining accuracyPreferred ExperienceProficiency with TruCare systemFamiliarity with Medicare and MedicaidJob DetailsSeniority level: AssociateEmployment type: ContractJob function: Health Care ProviderIndustries: Hospitals and Health Care and InsuranceNote: This description reflects the responsibilities and requirements for the Clinical Review Nurse – Prior Authorization role as part of our utilization management team. #J-18808-Ljbffr
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Utilization Review Nurse
3 weeks ago
Washington, United States SPECTRAFORCE Full timeOverview Title: Clinical Review Nurse Prior Authorization Review Location: Fully Remote (PST Time Zone - WA/OR Resident) Duration: 12-Month (Potential for Extension) About the Role We are seeking an experienced Clinical Review Nurse for Prior Authorization Review to join our Utilization Management team. In this role, you will conduct concurrent and prior...
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Utilization Review Manager
7 days ago
Washington, United States Virginia Hospital Center Full timePosition TitleUtilization Review ManagerJob DescriptionThe Utilization Review Manager oversees the utilization review process, ensuring efficient and effective use of hospital resources, compliance with regulatory requirements, and optimal patient care. The Utilization Review Manager will:Manage the utilization review team and processes.Conduct reviews of...
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RN - Utilization Review
2 weeks ago
Washington, United States Providence Health and Services Full timeRN - Utilization Review at Providence Health and Services summary:The Utilization Review Nurse evaluates patient admission status and ensures compliance with regulatory and payer requirements through utilization management. This role requires a registered nurse license with clinical nursing experience and expertise in utilization review, care management, or...
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Utilization Management Reviewer
3 weeks ago
Washington, United States AmeriHealth Caritas Full timeUtilization Management Reviewer Our Utilization Management Reviewers evaluate medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based on...
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RN Utilization Review
4 weeks ago
Washington, United States MedStar Health Full timeGeneral Summary of Position Conducts admission concurrent and retrospective case reviews to ensure appropriate admit status and level of care by utilizing the nationally approved guidelines. Collaborates with medical staff and ancillary hospital disciplines to ensure high-quality patient care in the most efficient way. Primary Duties and Responsibilities...
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RN Utilization Review
3 weeks ago
Washington, United States MedStar Health Full timeGeneral Summary of Position Conducts admission concurrent and retrospective case reviews to ensure appropriate admit status and level of care by utilizing the nationally approved guidelines. Collaborates with medical staff and ancillary hospital disciplines to ensure high-quality patient care in the most efficient way. Primary Duties and Responsibilities...
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RN Utilization Review
3 weeks ago
Washington, United States HH MedStar Health Inc. Full timeAbout the Job General Summary of Position Conducts admission concurrent and retrospective case reviews to ensure appropriate admit status and level of care by utilizing the nationally approved guidelines. Collaborates with medical staff and ancillary hospital disciplines to ensure high-quality patient care in the most efficient way. Primary Duties and...
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RN Utilization Review
4 weeks ago
Washington, United States MedStar Good Samaritan Hospital Full timeAbout The Job Conducts admission concurrent and retrospective case reviews to ensure appropriate admit status and level of care by utilizing the nationally approved guidelines. Collaborates with medical staff and ancillary hospital disciplines to ensure high-quality patient care in the most efficient way. Primary Duties and Responsibilities Conducts...
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Utilization Management Reviewer
5 days ago
Washington, DC, United States AmeriHealth Caritas Health Plan Full time$5,000.00 SIGN ON BONUSRole Overview Our Utilization Management Reviewers evaluate medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based...
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RN Utilization Review
2 weeks ago
Washington, DC, United States MedStar Health Full timeGeneral Summary of Position Conducts admission concurrent and retrospective case reviews to ensure appropriate admit status and level of care by utilizing the nationally approved guidelines. Collaborates with medical staff and ancillary hospital disciplines to ensure high-quality patient care in the most efficient way. Primary Duties and Responsibilities ...
