REMOTE Utilization Review RN

CareNational - San Francisco, CA4.1

Full-time

Utilization Review Nurse (RN) - Managed Care

Work From Home / TeleCommute

** Work-From-Home / Telecommute Opportunity - Must be a licensed nurse in California! **

** This is a full-time, benefits available, CONTRACT opportunity, expected to last 3 months, or longer! **

Utilization Review Nurse Job Summary:

  • The Utilization Review Nurse is responsible for utilization management and utilization review for prospective (prior authorization), concurrent, or retrospective review.
  • The Utilization Review Nurse will performs reviews of services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
  • Utilize clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
  • The Utilization Review Nurse will obtain the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs.

Utilization Review Nurse Background:

  • Current, valid, and unrestricted state Registered Nurse (R.N.) license.
  • CCM or CPUR or similar certification is preferred
  • 2 years acute care clinical nursing experience is required.
  • 1 year of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
  • Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
  • Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
  • Computer skills to include Microsoft Word, Excel, database use, and basic data entry.

Job Types: Full-time, Contract

Salary: $32.00 to $36.00 /hour

Experience:

  • acute care / clinical nursing: 2 years (Required)
  • Utilization Review at a Health Plan: 1 year (Required)

Job Location:

  • California (Required)

License or certification:

  • Registered Nurse (RN) (Required)