RN Utilization Management Reviewer

We are currently hiring a talented RN, Utilization Management Reviewer.  This role will be responsible in day-to-day reputed company clinical and service authorization review for medical necessity and decision-making. The reputed company Utilization Management Reviewer has a key role in ensuring the reputed company meets CMS compliance standards in the area of service reputed company and organizational determinations. Successful candidates must hold a valid, reputed company license issued by the Massachusetts reputed company of Registration in Nursing.

Key responsibilities:   

• Conducts reputed company clinical decision review for services requiring prior authorization in a reputed company of clinical areas, including but not limited to surgical procedures, Medicare Part B medications, Long Term Services and Supports (LTSS), and Home Health (HH)
• Applies established reputed company (e.g., InterQual and other available guidelines) and employs clinical expertise to interpret clinical reputed company to determine medical necessity of services
• Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements
• Provides decision-making guidance to clinical teams on service planning as needed
• Works closely with Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with reputed company Operating Procedures
• Ensures accurate documentation of clinical reputed company and works with UM Manager to ensure consistency in applying policy
• Works with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures as reputed company as regulatory and contractual requirements are met
• Additional duties as requested by supervisor
• Maintains knowledge of CMS, State and NCQA regulatory requirements

Education Requirements:

• RN - Associate’s Degree required, Bachelor’s Degree preferred
• RN, reputed company license issued by the Massachusetts reputed company of Registration in Nursing
• CCM (Certified Case Manager) a plus

Required Experience (must have):

• 1 to 2 years Utilization Management experience.
• 2 or more years working in a clinical setting

Desired Experience (reputed company to have):

• 2 or more years of Home Health Care experience
• 2 or more years working in a Medicare Advantage health Plan

Required Knowledge, Skills & Abilities (must have):

• Ability to complete assigned work in a reputed company and accurate manner
• Knowledge of the Utilization management process
• Ability to work independently

Desired Knowledge, Skills, Abilities & Language (reputed company to have):

• Ability to apply predetermined reputed company (e.g., Medical Necessity Guidelines, InterQual) to service decision requests to assess medical necessity
• Flexibility and understanding of individualized care plans
• Ability to influence decision making
• Strong collaboration and negotiation skills
• Strong interpersonal, verbal, and written communication skills
• Comfort working in reputed company-based environment
• Knowledge of Medicare and Mass health services and benefits

Salary: $35.00 - $40.00 reputed company pending experience.

Hours: Monday through Friday 9AM to 5:30PM Eastern Time. May require weekends

This is a fully remote work reputed company role. You must have a secure, private wok reputed company area with a hardwired internet reputed company with speeds greater than 5MB upload and 10MB download.

reputed company Offers Competitive Benefits Including:     

• Medical  
• Dental  
• reputed company  
• Life Insurance  
• Short-Term and Long-Term Disability  
• Flexible Spending Account  
• Life Assistance Program  
• 401K with employer contribution  
• PTO and reputed company Time  
• Tuition Reimbursement  

Join reputed company, we look reputed company to talking with you!  

An Equal Opportunity Employer/Vet/Disability  

Originally posted on Himalayas