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Clinical Utilization Review Specialist
2 months ago
Company Overview
Rising Medical Solutions is dedicated to transforming the healthcare landscape by enhancing the efficiency of healthcare claims through comprehensive bill review, case management, and utilization review.
Position Summary
We are currently seeking a qualified Utilization Review Nurse to join our team. This full-time role requires a commitment of 40 hours per week, Monday through Friday.
Key Responsibilities
As a Utilization Review Nurse, your duties will include:
1. Executing all components of the Utilization Review Process.
2. Evaluating records and requests for utilization review received through various channels.
3. Applying evidence-based guidelines to determine authorization eligibility or the need for further review.
4. Composing detailed nurse summaries for all utilization review cases.
5. Accurately documenting findings in Rising's database and preparing determination letters for each completed review.
6. Fostering collaborative relationships with clients, patients, providers, and other stakeholders.
7. Monitoring the status of all utilization review activities to ensure timely responses.
8. Maintaining organized records of clinical documentation related to all claims interactions.
9. Utilizing strong clinical judgment and critical thinking skills to assess cases.
10. Addressing inquiries regarding case status through written and verbal communication.
Qualifications
The ideal candidate will possess:
- An Associate's or Bachelor's degree in Nursing.
- An active and unencumbered RN license in one or more states.
- 3 to 5 years of clinical practice experience or 2 years of experience in case management and/or utilization review.
- Additional state licenses are advantageous.
- Familiarity with Workers' Compensation, disability claims, or liability claims.
- Strong organizational and time-management skills.
- Excellent analytical and communication abilities.
- Proficiency in data gathering and report preparation.
- Experience in a dynamic, fast-paced environment.
Technical Skills
Proficiency in Microsoft Word, Excel, and Outlook is required, along with the ability to remain composed in high-pressure situations and a customer-service-oriented mindset.
Benefits
We offer a competitive salary, profit-sharing opportunities, 401k matching, generous paid time off, and pathways for career advancement.
Company Culture
Rising Medical Solutions has been recognized as a Top Workplace in the healthcare sector, reflecting our commitment to a positive work environment.
