Nurse Reviewer for Utilization Management
2 weeks ago
The Utilization Management Nurse Reviewer is integral to healthcare operations, focusing on the efficient and appropriate use of medical services. This role involves reviewing patient records, treatment plans, and relevant information to assess the necessity and suitability of medical interventions, tests, and procedures.
In collaboration with healthcare professionals, insurance entities, and patients, the Utilization Management Nurse Reviewer aims to enhance healthcare delivery, manage costs, and uphold quality standards. Key responsibilities include:
- Evaluating medical services against established criteria to confirm their appropriateness and medical necessity.
- Reviewing patient documentation to ensure the quality of care and necessity of services rendered.
- Providing clinical insights and serving as a resource for non-clinical personnel.
- Managing essential clinical data within various medical management systems.
- Staying informed about regulatory requirements and state standards for utilization review.
- Applying clinical judgment to determine appropriate evidence-based guidelines.
- Facilitating high-quality patient care through effective communication with management, physicians, and the Medical Director.
Key Qualifications:
- Excellent written and verbal communication skills.
- Ability to maintain professional interactions with healthcare providers and clients.
- Strong multitasking abilities and adaptability in a dynamic work environment.
- Exceptional organizational skills and attention to detail.
- Proficient problem-solving capabilities.
- Experience with Microsoft Office Suite including Word, Excel, PowerPoint, and Outlook.
- Background in medical or clinical practice through education or professional experience.
- Valid and unrestricted LVN/RN license from an accredited program.
Additional Responsibilities:
- May oversee the work of team members.
- Continuously enhance processes to improve turnaround times and client satisfaction.
- Responsible for final case approvals prior to client release.
- Act as a liaison for quality issue reports and new reviewer assessments.
Educational Requirements:
Licensed Practical/Vocational Nurse with an active license to practice.
Experience Requirements:
A minimum of 2 years of clinical nursing experience is required, along with at least 1 year in Utilization Management.
Skills and Competencies:
Demonstrated proficiency in communication and interpersonal skills, alongside a solid understanding of computer operations, particularly with Microsoft applications. Ability to adapt and learn new skills as needed.
Work Environment:
This position may require physical activities such as lifting and bending, along with extended periods of sitting and computer use.
Remote Work Requirements:
Must maintain reliable internet service and an uninterrupted connection for remote work.
Compensation:
Compensation will be determined based on experience, education, and specific skills, complemented by a comprehensive benefits package including health insurance, retirement plans, and performance bonuses.
About Dane Street, LLC:
Dane Street is a dynamic, high-performance organization processing over 200,000 insurance claims annually. We specialize in Independent Medical Exams and Peer Review programs, assisting clients in achieving accurate medical determinations as part of their claims management processes.
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