Utilization Review RN
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At a glance
Requirements
Credentials this posting asks for.
Job overview
HealthcareSupport Staffing is hiring an Utilization Review RN. The Utilization Review RN ensures medically appropriate, high-quality, and cost-effective care by assessing the medical necessity of various services. This role involves applying clinical knowledge to coordinate care with facilities and providers, working with medical directors on care appropriateness, and managing appeals for denied services. The RN also conducts reviews to ensure compliance with medical policies and facilitates member care transitions.
Key focus areas include Ensure medically appropriate, high quality, cost effective care through assessing medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting, Apply clinical knowledge to work with facilities and providers for care coordination, and Work with medical directors in interpreting appropriateness of care and accurate claims payment.
Successful candidates bring Active RN License in OH, AS/BS in Nursing, and Acute Clinical Care Experience. Important skills include Care Coordination, Medical Necessity Assessment, Appeals Management, Pre-certification, Inpatient Review, and Retrospective Review.
Skills & qualifications
Skills
Qualifications
Benefits
Full job description
Daily Responsibilities:
- Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting
- Applies clinical knowledge to work with facilities and providers for care coordination
- Works with medical directors in interpreting appropriateness of care and accurate claims payment
- May also manage appeals for services denied
- Conducts pre-certification, inpatient, retrospective, out of network and 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
- Facilitates member care transition through the healthcare continuum
- Refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications
Hours for this Position: Monday-Friday (40 hours/week)
Advantages of this Opportunity:
- Competitive salary, negotiable based on experience
- Benefits offered, Medical, Dental, and Vision
- Fun and positive work environment
- Weekly deposit options
Requirements:
- Must have clear and active RN license in the state of OH
- AS/BS in Nursing
- Experience in acute clinical care
- Experience with medical record review/utilization review/utilization management
Are you an experienced Registered Nurse with Utilization review experience looking for a new opportunity with a prestigious healthcare company? Do you want the chance to advance your career by joining a rapidly growing company? If you answered “yes" to any of these questions – this is the position for you!
Interested in hearing more about this great opportunity? Please click apply or call Amanda Hammer at 407-636-7030 ext.201 for additional details.
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