About the job
The Utilization Management Nurse Reviewer is integral to healthcare systems, ensuring that medical services are utilized efficiently and appropriately. This role involves reviewing medical records, treatment plans, and patient information to ascertain the necessity and appropriateness of medical procedures, tests, and treatments.
As a Utilization Management Nurse Reviewer, you will collaborate with healthcare providers, insurance companies, and patients to enhance healthcare delivery, manage costs, and uphold quality care. Your responsibilities will include assessing medical necessity, coordinating care, conducting utilization reviews, offering recommendations for care plans, and ensuring compliance with regulations and guidelines. This position requires robust clinical knowledge, critical thinking skills, effective communication abilities, and the capacity to make informed decisions regarding patient care pathways.
Available Shifts:
- Sunday - Thursday 8:00 AM - 4:30 PM EST
- Monday - Friday 7:00 AM - 3:30 PM EST
- Tuesday - Saturday 9:00 AM - 5:30 PM EST
Key Responsibilities
- Conduct thorough assessments of medical services to validate their appropriateness using established criteria and guidelines, ensuring the medical necessity of treatments (e.g., CMS, Milliman Care Guidelines, InterQual, or health plan-specific guidelines).
- Evaluate patient records to verify the quality of care and necessity of services provided.
- Provide clinical expertise and serve as a reference for non-clinical staff.
- Input and manage essential clinical details within various medical management platforms.
- Stay informed about regulatory requirements (such as URAC) and state standards for utilization review.
- Apply clinical reasoning to determine suitable evidence-based guidelines.
- Promote efficient and high-quality patient care through effective communication with management teams, physicians, and the Medical Director.