Utilization Review Registered Nurse (RN)

Job Title: Utilization Review Registered Nurse (RN)

Job Duration: 3 months (possible extension)

Location: 100% Remote in Illinois

Pay Range: $37.97/hr to $40/hr on W2

Work Schedule/Shift & Time Zone:

• Monday-Friday 9am-5:30pm CST
• Rotating Saturday 7-11am CST
• Rotating Holidays

Day to Day Responsibilities:

• Review prior authorization and concurrent review requests using medical necessity criteria.
• Document determinations and rationale in UM systems within required turnaround times.
• Request additional clinicals and escalate non‐approved cases to the Medical Director per policy.
• Adhere to UM procedures, regulatory requirements, and productivity expectations.

Must Have Requirements:

• Active IL RN License

Description:

• Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing *** members with the right care at the right place at the right time.
• Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.
• Assesses services for Client Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

Essential Functions:

• Provides concurrent review and prior authorizations (as needed) according to Client policy for Client members as part of the Utilization Management team.
• Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for Client members including Behavioral Health and Long Term Care.
• Maintains department productivity and quality measures.
• Attends regular staff meetings.
• Assists with mentoring of new team members.
• Completes assigned work plan objectives and projects on a timely basis.
• Maintains professional relationships with provider community and internal and external customers.
• Conducts self in a professional manner at all times.
• Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct.
• Consults with and refers cases to Client medical directors regularly, as necessary. Complies with required workplace safety standards.

Knowledge/Skills/Abilities:

• Demonstrated ability to communicate, problem solve, and work effectively with people. Excellent organizational skill with the ability to manage multiple priorities.
• Work independently and handle multiple projects simultaneously.
• Knowledge of applicable state, and federal regulations.
• In depth knowledge of Interqual and other references for length of stay and medical necessity determinations.
• Experience with NCQA. Ability to take initiative and see tasks to completion.
• Computer Literate (Microsoft Office Products). Excellent verbal and written communication skills. Ability to abide by Clients policies.
• Ability to maintain attendance to support required quality and quantity of work.
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
• Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers.

#IRI-RN

Pay: $37.97 - $40.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance

Work Location: Remote

Salary : $38 - $40