Clinical Utilization Review Nurse

2 weeks ago

Phoenix, Arizona, United States Innovative Care Management, Inc. Full time

Position Overview:

Under the guidance of the Manager of the Utilization Review Program, the Utilization Review (UR) Nurse plays a crucial role in ensuring the efficient and precise management of initial medical necessity evaluations throughout the preauthorization and retrospective review processes.

Work Environment:

This position is primarily remote; however, due to payroll and tax regulations, candidates must reside in specific states: Arizona, Oregon, or Washington. Applicants must either live in or be willing to relocate to one of these states to qualify for this role.

Key Responsibilities:

  • Evaluate precertification requests to determine medical necessity.
  • Collaborate with the Appeals Specialist nurse for cases requiring additional expertise.
  • Assess clinical data for concurrent reviews, making decisions on extending hospital stays as necessary.
  • Utilize effective relationship management and coordination of services to:
    • Enhance the quality of care and life for patients.
    • Achieve cost-effective medical outcomes.
    • Avoid unnecessary hospital admissions.
    • Facilitate efficient hospital stay durations.
    • Ensure continuity of care for patients.
    • Guarantee appropriate levels of care are provided.
    • Offer consultation to various clinical and non-clinical personnel.
    • Support and foster collaborative relationships across all departments within Innovative Care Management.
    • Refer patients to Case Management, Disease Management, and Healthy Mother Baby programs as needed.
    • Document all communications and patient-related interventions accurately using ICM software.


Qualifications and Skills:

  • A minimum of 2 years of direct patient care experience as a Registered Nurse (RN) is required.
  • Strong verbal and written communication skills are essential.
  • Proficient computer skills are necessary, including the ability to effectively use software for communication in a remote setting and adapt to new software quickly.
  • Self-driven with the capacity to work independently and collaboratively in a business environment.
  • Excellent relationship management abilities, demonstrating psychological insight and assertiveness.
  • Proven problem-solving skills in complex and emotionally charged situations.
  • Ability to engage in abstract thinking.
  • Competence in conflict management, negotiating mutually beneficial solutions.
  • Strong organizational skills with an emphasis on task prioritization and delegation.
  • A deep commitment to patient advocacy and empathy.

Education and Certification:

  • Registered Nursing (RN) degree from an accredited nursing program is required.
  • A Bachelor's degree or higher in a health-related field is preferred.
  • Proof of successful completion of educational requirements for RN licensure in the respective state is mandatory, along with proof of active licensure in good standing.
  • Must complete continuing education to maintain active licensure in states where CEUs are mandated.
  • Ability to obtain additional state licenses as required.

Work Conditions:

  • Ability to maintain a secure and private workspace without interruptions during work hours.
  • Capability to sit or stand for 8-10 hours daily.
  • Ability to use a headset and communicate via telephone for extended periods.
  • Capacity to work in front of a computer screen and type for 8-10 hours each day.
  • Ability to lift and transport equipment and files, weighing less than 20 pounds, as necessary.


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