Utilization Review Nurse

Recruitment Manager @ Integrated Resources, Inc | Human Resources Management

Location: 100% Remote

Schedule: M-F 9:00am to 5:30pm with rotating Saturdays from 7-11am CST, including holiday rotation

• This position is fully remote, but candidates need to have an Illinois state RN license
• Assess and analyze clinical service requests (e.g., surgeries, outpatient therapies, DME) using evidence-based MCP/MCG criteria.
• Verify member benefits and eligibility
• Process prior authorization determinations within regulatory timelines
• Collaborate with multidisciplinary teams

• Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing clients' 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.
• Provides concurrent review and prior authorizations (as needed) according to Client policy for Client members as part of the Utilization Management team.
• Consults with and refers cases to Client medical directors regularly, as necessary. Complies with required workplace safety standards.

• Active, unrestricted IL State Registered Nursing (RN) license in good standing.

• 1-3 years of hospital or medical clinic, utilization review or prior authorization experience

Associate

Contract

Health Care Provider

Hospitals and Health Care and Public Health