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Clinical Utilization Management Nurse
2 months ago
The Utilization Management Nurse Reviewer is integral to the healthcare framework, focusing on the effective and appropriate use of medical services. This role involves scrutinizing medical documentation, treatment strategies, and patient data to assess the necessity and validity of medical interventions, diagnostic tests, and therapeutic procedures.
In collaboration with healthcare professionals, insurance entities, and patients, the Utilization Management Nurse Reviewer aims to enhance healthcare delivery, manage expenses, and uphold high standards of care. Key responsibilities encompass evaluating medical necessity, coordinating patient care, conducting utilization assessments, providing insights for care plans, and ensuring compliance with established regulations and guidelines. This position demands robust clinical expertise, analytical thinking, excellent communication skills, and the capacity to make well-informed decisions regarding patient care pathways.
Work Schedule:
- Start times at 9 am
- Start times at 11:00 am
- Weekend shifts of 10 hours (Thursday to Sunday) starting at 8 am
Primary Responsibilities:
- Perform evaluations of medical services to confirm their appropriateness based on established criteria and guidelines, ensuring the medical necessity of treatments (e.g., CMS, Milliman Care Guidelines, InterQual, or specific health plan criteria).
- Review and analyze patient records to ensure the quality of care and the necessity of services rendered.
- Provide clinical guidance and act as a resource for non-clinical staff.
- Input and manage vital clinical information within various medical management systems.
- Stay informed about regulatory requirements (such as URAC) and state standards for utilization review.
- Utilize clinical judgment to apply suitable evidence-based guidelines.
- Promote efficient and high-quality patient care through effective communication with management teams, physicians, and the Medical Director.
Qualifications:
- Excellent written and verbal communication skills.
- Ability to maintain professional interactions with physicians and clients.
- Proficient in multitasking and adapting quickly in a dynamic office environment.
- Strong organizational skills with a keen attention to detail.
- Adept at solving complex and multifaceted issues.
- Familiarity with Microsoft tools such as Word, Excel, PowerPoint, and Outlook.
- Background in medical or clinical practice through education, training, or professional experience.
- Possession of an unrestricted LVN/RN license from an accredited vocational nursing program (for LVNs) or a nursing degree from an accredited institution (for RNs).
Additional Responsibilities:
- May oversee the work of team members.
- Continuously enhance processes to improve turnaround times, peer-to-peer success rates, and reduce client requests for clarification, ultimately increasing client satisfaction.
- Responsible for the final approval of cases prior to client release.
- Act as a liaison to coordinate quality issue reports and new reviewer reports with the VP of Clinical Operations.
Education and Credentials:
Licensed Practical/Vocational Nurse with an active and unrestricted license to practice.
Relevant Experience:
A minimum of 2 years of clinical nursing experience is required.
At least one year of prior experience in Utilization Management is necessary.
Skills and Competencies:
Demonstrated proficiency in both spoken and written communication, alongside effective interpersonal skills. Strong understanding of computer operations, particularly the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows. Ability to acquire new skills and competencies to meet the evolving demands of systems, software, and hardware.
Working Conditions:
May involve lifting, bending, and traveling as necessary to fulfill job duties. Prolonged periods of sitting and computer work are expected.
Remote Work Requirements:
Must provide and maintain their own internet services. An uninterrupted internet connection is a requirement for all remote positions.
Compensation:
Starting compensation will vary based on several factors, including the candidate's experience, education, and specific skills. In addition to the base salary, a comprehensive benefits package is offered, including health insurance, retirement plans, and performance bonuses.
Our Commitment:
We are dedicated to providing fair and competitive compensation that reflects each employee's contributions and performance. We value diversity and strive to create an inclusive environment for all employees.
Benefits:
Join our team at Dane Street and enjoy a comprehensive benefits package designed to support your well-being and peace of mind. We offer a range of benefits including medical, dental, and vision coverage for you and your family. Additional voluntary life insurance options are available for you, your spouse, and your children. Other voluntary benefits include hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost. Our generous paid time off policy ensures you have time to relax and recharge, while our 401k plan with a company match helps you plan for your future. Apple equipment and a media stipend are provided for remote workspace.
About Dane Street:
A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers' Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.
