What are the responsibilities and job description for the Utilization Review Nurse position at Careers Integrated Resources Inc?
Job Title: Utilization Review Nurse
Job Location: Bothell, WA
Job Duration: 4 Months (possibility of extension)
Shift: 8am - 5pm CST or 9am - 6pm CST/PST/EST
PayRate: $42/hr.on w2
Job Summary:
- Works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential.
- Client staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.
Day to Day Responsibilities:
- Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
- Analyzes clinical service requests from members or providers aProductst evidence based clinical guidelines.
- Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
- Conducts prior authorization reviews to determine financial responsibility for *** and its members.
- Processes requests within required timelines.
- Refers appropriate prior authorization requests to Medical Directors.
- Requests additional information from members or providers in consistent and efficient manner.
- Makes appropriate referrals to other clinical programs.
- Collaborates with multidisciplinary teams to promote Client Care Model.
- Adheres to UM policies and procedures.
Education:
-
Completion of an accredited Registered Nurse (RN).
Required Experience:
- 1–3 years of hospital or medical clinic experience.
- 1 year Prior Authorization or Utilization Management.
Required License, Certification, Association:
-
Active, unrestricted State Registered Nursing (RN) license in good standing.
Required Years of Experience:
-
2 years Prior Auth, MCO and/or UM Experience preferred.
Required Licensure / Education:
-
Active, unrestricted State license in good standing (RN).
Salary : $42
