Utilization Review Nurse/ RN for Imaging/Commercial- Remote!

City/State

Work Shift

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  Utilization Review Nurse is responsible for utilizing management services within the scope of licensure.

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  Conducts primary functions of prior authorization, inpatient review, concurrent review, retrospective review, medical director referrals and execution of member/provider approval and/or denial letter.

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  Reviews provider requests for services requiring authorization. Conduct 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.

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  May manage appeals for services denied. Responsible for written and/or verbal notification to members and providers.

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  Demonstrates proactive anticipatory discharge planning; serves as joint transition of care coordinator with case management and facilitates member care transition.

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  Ensures medical director’s written decision is consistent with criteria (CMS, state, medical policy, clinical criteria).

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  Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

• Bachelors Degree in Nursing preferred

• 3 years of acute care clinical experience REQUIRED

• Previous Utilization Review experence highly preferred

• Previous imaging experience preferred

• InterQual or Milliman experience preferred.

• Knowledge of NCQA preferred

Talroo - Nursing

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