Utilization Review Nurse
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At a glance
Requirements
Credentials this posting asks for.
Job overview
US Tech Solutions is hiring an Utilization Review Nurse. The Utilization Review Nurse participates in developing and implementing Quality Management Work Plan activities. This role involves improving quality products and services through measurement and analysis, making recommendations to meet QM objectives. The nurse reviews documentation, evaluates potential Quality of Care issues, and ensures compliance with clinical policies and regulatory guidelines. They also coordinate clinical resolutions and process complex data.
Key focus areas include Review documentation and evaluate Potential Quality of Care issues based on clinical policies and benefit determinations, Consider all documented system information and additional records/data to develop a determination or recommendation, and Navigate multiple system applications for data gathering.
Successful candidates bring RN Experience 3+ Years, Inpatient Hospital Experience 1+ Years, and Active Unrestricted RN Licensure. Important skills include MEDCOMPASS, ASSURECARE, Managed Care, Medicare Knowledge, Medicaid Knowledge, and UM Experience. Preferred (not required): Milliman Knowledge and MCG Knowledge.
Skills & qualifications
Skills
Qualifications
Full job description
Please note: Actual location may vary., RI
Contract
Job Description:
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Participates in the development and ongoing implementation of QM Work Plan activities.
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Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives
Responsibilities:
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Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.
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Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
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Data gathering requires navigation through multiple system applications.
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Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
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Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
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Responsible for the review and evaluation of clinical information and documentation.
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Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.
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Works Potential Quality of Care cases across all lines of business (Commercial and Medicare).
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Independently coordinates the clinical resolution with internal/external clinician support as required.
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Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data
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Prepares and completes QM documents based on interpretation and application of business requirements
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Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements
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Assists in the development and implementation of QM projects and activities
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Accountable for completing and implementation of QM Work Plan Activities
Experience:
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3+ years of experience as an RN
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1+ years of inpatient hospital experience
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Registered Nurse in state of residence
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Must have prior authorization utilization experience
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Able to work in multiple IT platforms/systems
Skills:
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MUST HAVE MEDCOMPASS or ASSURECARE exp.
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MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.
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MUST HAVE UM experience, inpatient utilization management review.
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MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.
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MUST HAVE 6 months of Prior Authorization.
Education:
- Active and unrestricted RN licensure in state of residence
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com (http://www.ustechsolutionsinc.com/) .
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
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