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Utilization Review Nurse
2 months ago
We are seeking a highly skilled Utilization Review Nurse to join our team at US Tech Solutions, Inc. As a key member of our healthcare team, you will play a critical role in ensuring the quality and cost-effectiveness of healthcare services for our members.
Key Responsibilities- Medical Necessity Reviews: Conduct thorough reviews of medical or behavioral eligibility to determine benefits and clinical criteria, applying clinical expertise, administrative policies, and established clinical criteria to service requests or provide health management program interventions.
- Clinical Proficiency: Utilize clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of the healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness.
- Resource Utilization: Utilize allocated resources to back up review determinations, identify and make referrals to appropriate staff, and participate in data collection/input into systems for clinical information flow and proper claims adjudication.
- Discharge Planning: Provide discharge planning and assess service needs in cooperation with providers and facilities, evaluating outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
- Communication: Provide appropriate communications (written, telephone) regarding requested services to both healthcare providers and members, and participate in direct intervention/patient education with members and providers regarding healthcare delivery systems, utilization on networks, and benefit plans.
- Education: Associate Degree in Nursing or Graduate of Accredited School of Nursing or Master's degree in Social Work, Psychology, or Counseling.
- Experience: 4 years recent clinical experience in a defined specialty area, or 4 years utilization review/case management/clinical/or combination experience, with 2 of 4 years must be clinical.
- Licensure: Active, unrestricted RN licensure from the United States and in the state of hire, or active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
- Software and Tools: Microsoft Office, working knowledge of spreadsheet, database software, and preferred software and tools including Microsoft Excel, Access, or other spreadsheet/database software.
- Knowledge and Skills: Working knowledge of word processing software, quality improvement processes, contract language and application, ability to work independently, prioritize effectively, and make sound decisions, good judgment skills, demonstrated customer service, organizational, and presentation skills, and demonstrated proficiency in spelling, punctuation, and grammar skills.
US Tech Solutions, Inc. is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. We are an Equal Opportunity Employer and welcome qualified applicants from diverse backgrounds to join our team.
