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Utilization Management Nurse (Remote)

Medix

This is a Contract position in Raleigh, NC posted October 26, 2021.

Medix is looking for a self-motivated and passionate Registered Nurse for our Full-Time Remote Utilization Management Nurse opening. The Utilization Management Nurse performs clinical reviews to assess medical necessity of a broad range of outpatient and inpatient services, while maintaining compliance with all regulatory requirements. Interfaces with medical directors, and both internal and external stakeholders, with regard to coverage for services, contract benefits and alternate resources available.

ESSENTIAL FUNCTIONS, RESPONSIBILITIES AND DUTIES:

  • The Utilization Management Review Nurse makes coverage determinations based on specific criteria including Interqual
  • Communicates and collaborates frequently with treating/referring providers in the gathering of clinical information and may also provide education on the medical review process.
  • Frequently collaborates and communicates with physician peer reviewers and medical directors in determining coverage of requested services.
  • Communicates decision post review directly with patient, Provider who ordered the service and Provider for whom the service was referred.
  • Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria – prospective, concurrent and retrospective review
  • Able to match patient care needs to available resources at the appropriate level of care and make adjustments if necessary
  • Provide intervention and coordination to decrease delays and denials
  • Maintains timely, complete and accurate documentation in compliance with policies and procedures
  • Support Quality and Performance Improvement Initiatives
  • Timely follow-up on results of denial and internal appeal reviews.
  • Review adverse determination language to ensure appropriateness.
  • Assist with external appeals in the absence of Appeals RN

3-5 Must Have Skills/Qualifications:

  • Current Active NYS RN license to practice professional nursing with no restrictions.
  • Minimum two years utilization review experience at a Managed Care Organization or Health Plan required.
  • One year recent discharge planning strongly preferred
  • Is able to apply Interqual Care Guidelines and other applicable, evidenced-based clinical guidelines
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