UTILIZATION MGMT NURSE RN
The Judge Group Inc.

Location: REMOTE
Salary: commensurate
Description: Our client is currently seeking a Utilization Management RN for a remote role.

Duties:

• Performs utilization review activities, concurrent, and retrospective reviews according to guidelines
• Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines / criteria
• Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services
• Answers Utilization Management directed telephone calls; managing them in a professional and competent manner
• Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy
• Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received concerning case communication and all demographic and service group information. Sends appropriate system-generated letters to provider and member
• May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
• Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department

MUST HAVE Qualifications & Requirements:

• Prior experience with Milliman Care Guidelines (MCG) and/or InterQual
• Microsoft Office suite including Excel
• Previous Prior Authorization experience
• Telephonic and/or telecommute experience
• Utilization Review / Management experience
• ICD-10, CPT coding knowledge / experience

Educational Requirements

• Active RN licensure - compact preferred!
• BSN preferred

All interested and qualified candidates must send resumes to Caroline Cristini at CCristini@judge.com for consideration. Please include the reference ID in the subject of your email along with your RN licensure number and compact status.

Contact: ccristini@judge.com

This job and many more are available through The Judge Group. Find us on the web at www.judge.com

This job has expired.