Utilization Review Nurse
Location: Fully Remote
Pay: $52.75/hr
Description:
Review patient cases and treatment plans remotely, ensuring appropriate use of healthcare resources.
Responsibilities:
- Conduct clinical reviews of medical records to determine the appropriateness of care.
- Collaborate with healthcare providers to obtain necessary clinical documentation.
- Apply clinical guidelines and insurance criteria (e.g., MCG, InterQual) to support authorization decisions
- Maintain accurate documentation for all reviews and communications.
- Escalate complex cases to physicians or managers as appropriate.
- Stay current with regulatory and compliance standards for utilization management.
- Participate in quality improvement and training activities.
Qualifications:
- Registered Nurse (RN) with an active, unrestricted license.
- Minimum of 3 years of clinical experience; prior utilization review or case management preferred.
- Familiarity with medical terminology, insurance plans, and clinical review criteria.
- Excellent analytical, communication, and documentation skills.
- Tech-savvy with experience using healthcare software and working in remote teams.
- Able to work independently in a fully remote environment.