[Hiring] Utilization Review Nurse @Martin’s Point Health Care

Role Description

The Utilization Review Nurse is responsible for ensuring high-quality, cost-efficient medical outcomes for enrollees needing inpatient/outpatient authorizations. This position involves:
• Receiving and reviewing prior authorization requests for specific inpatient and outpatient medical services.
• Completing inpatient concurrent reviews and establishing discharge plans.
• Coordinating transitions of care to lower/higher levels of care.
• Making referrals for care management programs.
• Performing medical necessity reviews for retrospective authorization requests and claims disputes.
• Using governmental policies and specified clinical guidelines to guide medical necessity reviews.
• Managing effective relationship coordination, resource management, education, and patient advocacy.

Qualifications
• 3+ years of clinical nursing experience as an RN, preferably in a hospital setting.
• 2+ years of utilization management experience in a health plan UM department.

Requirements
• Compact RN License.
• Certification in managed care nursing or care management desired (CMCN or CCM).
• Coding/CPC desired.
• Proficiency in conducting prospective, concurrent, and retrospective reviews using standardized criteria and guidelines like MCG.
• Ability to review and interpret medical records, treatment plans, and clinical documentation.
• Thorough understanding of healthcare policies, insurance guidelines, and regulatory standards (e.g., Medicare, NCQA, TRICARE).
• Familiarity with coding systems like ICD-10 and CPT.
• Technical savvy and ability to navigate multiple systems and screens while working cases.
• Ability to analyze data metrics, outcomes, and trends.
• Excellent interpersonal, verbal, and written communication skills.
• Critical thinking skills to identify root causes and understand coordination of medical and clinical information.
• Ability to prioritize time and tasks efficiently and effectively.
• Ability to manage multiple demands and function independently.
• Computer proficiency in Microsoft Office products including Word, Excel, and Outlook.

Benefits
• Organizational culture of trust and respect.
• Continuous learning opportunities.
• Supportive work environment focused on employee well-being.