Utilization Review Nurse (Remote)

Contract Length: 6 Month Contract with Potential Extension

Start Date: ASAP

Location: Fully remote

Reason for the openings: Anthem has an absurd leave of absence policy where their internal employees basically have no limit for how long they can be on leave, which leaves their team with a lot of extra work on their plate. They are about 3000 cases backlogged and need some help pushing those through the system. They will be given 15-20 cases to review each day.

Top Skillsets:

• 3+ years of URN Experience - specifically inpatientIf we can find 1 person with team lead exp. or just 5+ years of exp, we can slot them into "team lead"

• Fair amount of clinical knowledge; ICU and ER knowledge is great to have, but not mandatory
• Experience triaging, prioritizing and working in a high speed environment
• Great computer and technology skills; documentations skills and critical thinking
• EMR experience is a plus (no specific EMR, just in general)
• Experience with InterQual or DRG - not mandatory but will help with learning curve in training.
• Have to have RN; CMCN certification is a plus but not mandatory

Primary Responsibilities:

• Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.
• Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
• Collaborates with providers to assess member’s needs for early identification of and proactive planning for discharge planning.
• Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Other Responsibilities:

• Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
• Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, our of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards accurately interpreting benefits and managed care products and steering members to appropriate providers, programs, or community resources.
• Works with medical directors in interpreting appropriateness of care and accurate claims payment.
• May also manage appeals for services denied.

Job Types: Full-time, Contract

Benefits:

• Dental insurance
• Health insurance
• Vision insurance

Physical setting:

• Inpatient

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday
• Weekend availability

Experience:

• Utilization review: 2 years (Required)

License/Certification:

• Compact State Nurse License (Required)

Work Location: Remote

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