Utilization Review Nurse Specialist

1 day ago


Washington, Washington, D.C., United States Medix Full time
Job Summary

Medix is seeking a skilled Utilization Review Nurse to join our team. As a Utilization Review Nurse, you will play a critical role in ensuring that patients receive necessary and effective care while optimizing resource utilization.

Key Responsibilities
  • Assessment and Review: Conduct thorough assessments of patient care, review medical records and care plans to ensure that treatments are necessary and effective.
  • Coverage Determination: Decide on coverage for patient care, determining if healthcare insurance will cover specific care and communicating with patients about their insurance options and limitations.
  • Collaboration and Communication: Collaborate with insurance companies, social work, and quality improvement teams to ensure seamless care coordination.
  • Recommendations and Decision-Making: Make recommendations and decisions regarding patient care, including determining the length of hospital stays and evaluating the effectiveness of care plans.
  • Clinical Appeals: Evaluate clinical appeals, assessing patient care services to determine if they should be approved or denied.
Requirements
  • Healthcare Experience: Possess experience in health plan reviews, including dermal medicine, home health, and rehabilitation.
  • Hospital Experience: Have experience working in a hospital setting, with a focus on pediatric inpatient admissions and authorization, long-term care, skilled nursing, and behavioral analysis.
  • Interqual or Milliman Experience: Possess experience with Interqual or Milliman, with a focus on healthcare utilization review.
What We Offer

As a Utilization Review Nurse at Medix, you will have the opportunity to work with a diverse population and make a meaningful impact on patient care. We offer a dynamic and supportive work environment, with opportunities for professional growth and development.



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