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Utilization Review Nurse
1 month ago
Hines & Associates Inc. is a nationwide, independent leader in personalized managed health care, focused on delivering comprehensive services with program excellence and cost containment. With over three decades of innovative and professional health care excellence, Hines has established a reputation as an industry leader.
Our Mission:
We strive to conserve health care dollars while ensuring quality care through effective programs and personalized service. Our team of dedicated professionals is committed to delivering exceptional results and exceeding our clients' expectations.
What We Offer:
- Competitive salary and benefits, including medical, dental, vision, long-term care, short-term disability, long-term disability, and company-paid life insurance.
- 401k plan with company match, fully vested after 1 year.
- No weekends and nights.
- Paid Holidays.
- Work-life balance.
- Remote/hybrid setting (once trained).
Job Summary:
This is a Monday through Friday position, 9:30 AM to 6:00 PM. We are seeking a skilled and experienced Registered Nurse to join our team as a Utilization Review Nurse. The successful candidate will utilize clinical knowledge and communication skills to obtain patient-specific information regarding patient condition and proposed treatments and procedures.
Responsibilities:
- Completes first-level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review.
- Demonstrates ability to assess a patient's current medical status, including complications and untoward events, which may require additional intervention.
- Demonstrates a thorough understanding of criteria sets and their limitations, including when a second-level review is required.
- Evaluates appropriateness of current plan of care.
- Assesses aftercare needs, implements discharge planning, and/or case management referral in a timely manner.
- Maintains knowledge of current advances and trends in medical care.
- Demonstrates knowledge of URAC guidelines, Hines policies and procedures, and standards of practice and their revisions.
- Demonstrates assertiveness in completion of precertification and concurrent review within the guidelines of URAC, disability, workers compensation regulations, and state and federal requirements and according to the Hines policies and procedures.
- Performs onsite evaluations as needed or requested.
- Additional responsibilities as assigned.
Requirements:
- Registered Nurse with valid, unrestricted, current nursing license in the state or territory of the United States where employed.
- Successful completion of UR nurse orientation program.
- Minimum of 3 years recent acute clinical practice required, 5 years preferred.
- Managed care, disability, or workers compensation experience helpful but not mandatory.
- Customer service oriented.
Hines welcomes diversity and as an equal opportunity employer, all qualified applicants will be considered regardless of race, religion, color, national origin, sex, age, sexual orientation, gender identity, disability, or protected veteran status.
