REMOTE Utilization Review Nurse - Managed Care

Welcome and thank you for considering a career at Advanced Health!

We are searching for collaborative, innovative people committed to a shared community vision for health to join our team. If you value being part of a team that makes a difference, please consider joining our team!

• Competitive wages
• Paid Time Off (PTO), Sick leave, Health and life insurance, Flexible Spending- and Health Savings Account options, Tuition reimbursement, 401(k) and Roth retirement with generous employer match, and Profit-sharing

Team-oriented atmosphere that values each of our employees as an individual and their work-life balance

• Remote work options and Flexible scheduling

Every employee shares the responsibility for achieving the Quadruple Aim of health care reform: member engagement and satisfaction, improving quality of care, managing costs, and honoring diversity and equity
. By focusing on the people and communities we serve, we strive to ensure the dignity, privacy and confidentiality of members, their families, co-workers, and others. All duties are performed in compliance with organization’s policies and procedure, contractual obligations, and within federal and state laws and guideline including HIPAA, OSHA, and Waste Fraud and Abuse regulations.

Advanced Health, LLC team members are employed through Advanced Health and/or DOCS Management Services.

Location: Coos Bay, OR

Job :296-DOCS.UR.07

# of Openings:1

We are currently hiring a Part-time REMOTE Utilization Review Nurse
. If you are a licensed nurse with excellent critical thinking skills, have experience in acute care settings and utilization review, and value being part of a team that makes a difference, you may be the right person for the position!
Apply today!

Classification: NON-EXEMPT |
Status &

Schedule:

PART-TIME, 20-HRS/WEEK, GENERALLY MONDAY – FRIDAY, BUT MAY INCLUDE ADDITIONAL HOURS TO MEET THE NEEDS OF THE POSITION

Location: REMOTE, LOCAL TO OREGON STRONGLY PREFERRED

Work Location: OR, CA, AZ, TX, FL

Salary: $35.29 - $47.37/HOURLY

Department: MEDICAL SERVICES/UTILIZATION REVIEW |
Reports to: DIRECTOR OF MEDICAL SERVICES |
Supervision Exercised: NON-SUPERVISORY

JOB PURPOSE: Utilization Review Nurse

The Clinical Review Nurse is responsible for providing clinically efficient and effective utilization management. Reviews prior authorization requests for appropriate care and setting by following evidence based clinical guidelines, medical necessity criteria and health plan guidelines. Reviews and applies hierarchy of criteria to all referral and preauthorization requests from the PCPs and specialists that require a medical necessity determination. Is involved in assuring that the patient receives high-quality cost-effective care.

Uses sound clinical judgement and managed care principles in the coordination of care. Prepares any case that does not meet medical necessity guidelines for medical appropriateness of procedure, service, or treatment for review with the Physician Reviewer for a decision.

• Nursing degree from an accredited nursing program
• Experience with a similar population in health plans or managed care
• Experience administering OHP, Medicare benefits or utilization review highly preferred.

• Maintains clinical expertise and knowledge of scientific progress in nursing and medical arena and incorporates this information into the clinical review and care coordination processes
• Performs clinical review for appropriate utilization of medical services by applying appropriate medical necessity criteria guidelines
• Authorizes healthcare services in compliance with contractual agreements, Health Plan guidelines and appropriate medical necessity criteria
• Provides accurate and timely documentation within internal system supporting rationale of decision based on clinical review
• Identifies members who are appropriate for care coordination programs and collaborates with the Medical Management team for care coordination of the member's needs along the continuum of care
• Meets timeliness standards for referral and prior authorization activities
• Sends appropriate notifications for Third Party Liability (TPL) and/or possible Stop Loss
• Forward relevant information of members requiring special interventions to Advanced Health
• Participate in quality and organizational process improvement activities and teams when requested
• Assist in audit preparation as directed
• Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
• Handle confidential information and materials appropriately and maintains a secure work area
• Maintains the confidentiality of all company procedures, results, and information about patients, contracts, and all other proprietary information regarding company business.
• Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
• Handle confidential information and…