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Clinical Utilization Review Nurse
2 months ago
We are seeking a highly skilled Clinical Utilization Review Nurse to join our team at US Tech Solutions, Inc. As a key member of our healthcare team, you will be responsible for reviewing and evaluating medical or behavioral eligibility regarding benefits and clinical criteria.
Key Responsibilities- Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions.
- Utilizes clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of 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.
- Ensures coverage for appropriate services within benefit and medical necessity guidelines.
- Participates in data collection/input into system for clinical information flow and proper claims adjudication.
- Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies.
- 4 years recent clinical experience in a defined specialty area, such as oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, or general medicine/surgery.
- 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).
- Working knowledge of word processing software, quality improvement processes, and contract language and application.
- Ability to work independently, prioritize effectively, and make sound decisions.
- Working knowledge of spreadsheet, database software, and claims/coding analysis, requirements, and processes.
- Thorough knowledge/understanding of claims/coding analysis, requirements, and processes.
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 applications from diverse candidates.
