RN - Utilization Review; Remote

The Utilization Review Specialist is responsible for the assessment and review of the healthcare delivery system with a concentration on tasks that promote cost‑effective quality care and cost containment in accordance with various federal and/or state statutes, regulations and guidelines as well as facility policy.

• Perform utilization review in accordance with all state mandated regulations
• Analyze insurance, governmental and accrediting standards to determine criteria concerning admissions, treatment, and length of stay
• Assure compliance with state and federal regulations and billing requirements
• Maintain compliance with regulation changes affecting utilization management
• Review patient records and evaluate patient progress
• Ensure high standard of patient care by establishing best practice benchmarks
• Obtain and review necessary medical reports and related treatment plan to conduct review
• Review and validate physician’s orders, reports progress, and unusual occurrences on patients
• Ensure appropriate and cost‑effective healthcare services to patients
• Analyze patient records and participate in interdisciplinary collaboration with professional staff
• Facilitate educational programs as directed to keep physicians and professional staff informed about regulations affecting utilization management
• Recognize and report appropriately cases of fraud, abuse or incorrect utilization
• Consult with Social Services Department regarding the level of nursing care and collaborate with other departments in evaluation of projects affecting discharge plans
• Support performance improvement programs
• Perform continuing review on medical records and identify and evaluate need of ongoing hospitalization and services

• Current license for the state in which the nurse practices if nursing licensure is required by contract
• A Bachelor’s Degree in Nursing or at least two years’ experience in Utilization Review preferred
• Certification in Utilization Review or Utilization Management preferred
• Experience with Microsoft Office Suite and the ability to learn new information systems and software programs
• Strong problem solving, project management and organizational skills with an ability to work in a fast paced environment
• General knowledge of managed care delivery system
• Compliance with all relevant professional standards of practice
• Participation and completion of Amergis’ Competency program when applicable
• Current CPR if applicable
• TB questionnaire, PPD or chest x‑ray if applicable
• Current Health certificate (per contract or state regulation)
• Must meet all federal, state and local requirements
• Successful completion of new hire training as applicable to job site
• Understand patient confidentiality and HIPAA requirements
• Ability to effectively elicit/provide information to and from appropriate individuals (including, but not limited to, supervisors, co‑workers, clients) via strong communication skills; proficiency in the English language is required
• Computer proficiency required
• Must be at least 18 years of age

• Competitive pay & weekly paychecks
• Health, dental, vision, and life insurance
• 401(k) savings plan
• Awards and recognition programs

* Benefit eligibility is dependent on employment status.

Amergis is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected Veteran status, age, or any other characteristic protected by law.