Utilization Review Nurse

Overview

Rising Medical Solutions has an opening for a Utilization Review Nurse. We are a bill review and cost containment company focused on fixing the broken healthcare system by reducing the cost of healthcare claims through bill review, case management, and utilization review. Our mission is "To make lives better" and everyone here works hard to achieve this goal.

Full‑time position – 40 hours per week. Must work Monday through Friday.

• Perform all aspects of the Utilization Review Process
• Review records and requests for UR, which may arrive via mail, e‑mail, fax, or phone
• Utilize evidence‑based guidelines to determine if authorization can be given versus sending the file for Peer or Physician Review
• Write nurse summaries on all UR files
• Document properly in Rising's database (and client databases when appropriate), and send determination letters on each completed UR
• Establish collaborative relationships with clients, patients, employers, providers and attorneys
• Track ongoing status of all UR activity so that appropriate turnaround times are met
• Maintain organized files containing clinical documentation of interactions with all parties of every claim
• Utilize good clinical judgment, careful listening, and critical thinking and assessment skills
• Respond to various written and telephonic inquiries regarding status of case
• Must be proficient in the use of a computer, including the use of multiple software programs simultaneously

• An Associate's or Bachelor's degree in Nursing
• Hold an active and unencumbered RN license in one or more states
• 3 to 5 years of clinical practice experience or 2 years of case management and/or UR experience
• More than one state license (a plus)
• Experience with Workers' Compensation, short‑term or long‑term disability, or liability claims
• The ability to set priorities and work both autonomously and as a team member
• Well‑developed time‑management, organization, and prioritization skills
• Excellent analytical skills
• Superb oral and written communication
• The ability to gather data, compile information, and prepare summary reports
• Strong interpersonal and conflict resolution skills
• Experience in a fast‑paced, multi‑faced environment
• Demonstrated persistence and attention to detail
• General understanding of CPT and ICD‑9/ICD‑10 codes and Medicare guidelines
• Working knowledge of Microsoft Word, Excel, and Outlook
• Ability to remain calm during stressful situations
• A customer‑service mindset

• Generous Flexible Time Off
• Comprehensive benefit package including health, dental, vision insurance, profit sharing, and 401(k) matching
• Career Growth Opportunities – often promote from within
• Professional Development Reimbursement Program (PDRP)
• Part of the Elevate program designed to recognize and reward employees for hard work
• Rising was named a Top Workplace in the healthcare industry for 2023
• We are on You Tube to showcase our culture