Utilization Review Nurse

Change Healthcare - Pensacola, FL3.2

30+ days agoFull-timeEstimated: $54,000 - $74,000 a year
EducationSkillsBenefits
Transforming the future of healthcare isn’t something we take lightly. It takes teams of the best and the brightest, working together to make an impact.
As one of the largest healthcare technology companies in the U.S., we are a catalyst to accelerate the journey toward improved lives and healthier communities.
Here at Change Healthcare, we’re using our influence to drive positive changes across the industry, and we want motivated and passionate people like you to help us continue to bring new and innovative ideas to life.

If you’re ready to embrace your passion and do what you love with a company that’s committed to supporting your future, then you belong at Change Healthcare.
Pursue purpose. Champion innovation. Earn trust. Be agile. Include all.
Empower Your Future. Make a Difference.
RN required

3+ years of relevant experience

Arizona or Multi State Nursing License required

Performs initial, concurrent, and/or retrospective review of services that require prior authorization or medical appropriateness review using health plan benefits, clinical appropriateness criteria, or plan guidelines/protocols.
Documents clinical appropriateness reviews and care management activities in managed care operating systems
Facilitates cost effective and quality patient care by effective communication with physicians, providers and members.
Maintains knowledge of regulatory requirements (i.e. URAC), and state utilization review standards.
Ensures authorized services are performed in the most cost effective appropriate setting
Coordinate discharge planning activities for inpatient level of care services and facilitate referral to care management programs
Participate in case review and/or team meetings with managerial team and Medical Director

Competencies:
Strong critical thinking and Analytical
Strong verbal and written communication skills
Knowledge of healthcare
Medical terminology
Excellent computer literacy and beginning to moderate skills level with Microsoft Word and Excel
Strong interpersonal skills
Able to work independently
MINIMUM JOB Qualifications

Education / Training:
Required: Registered Nurse with an active nursing licenses to practice in the state of the contracted Client (i.e. Florida, Arizona etc.).
Preferred: Bachelor’s Degree in Nursing

Business Experience:
Minimum of 3-5 years of clinical experience
One year of care management, utilization management experience, clinical documentation or clinical auditing experience
Successful work history in a clinical setting and/or health insurance environment
SPECIALIZED KNOWLEDGE / SKILLS

Knowledge of medical appropriateness criteria such as InterQual®, Milliman Care Guidelines®
Knowledge of CPT, ICD-10, and/or HCPC codes or coding experience
Knowledge of precertification and/or medical review processes in a health care payor or third party
Environment.

Knowledge of URAC or NCQA standards

WORKING CONDITIONS:
Office Environment, Office cubicle, indoors, heated/air-conditioned office
No heavy lifting of anything greater than 10 pounds and no extensive standing. Uses personal computer, copy machine, and fax machine on a regular basis.
Join our team today where we are creating a better coordinated, increasingly collaborative, and more efficient healthcare system!

Equal Opportunity/Affirmative Action Commitment

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.