Utilization Review Nurse/REMOTE (Contract-to-Hire to $50/hour)

  • Novus Group
  • Remote * (Pittsburgh, PA, USA)
  • Jan 15, 2022
Healthcare Nursing Telecommuting

Job Description

Th e Utilization Review Nurse performs prospective/concurrent reviews and identifies issues related to professional and facility provider claims data including determining appropriateness of code submission, analysis of the claim rejection and the proper action to complete the retrospective review with the goal of proper and timely payment to provider and member satisfaction. The incumbent implements effective utilization management strategies on a prospective, concurrent and retrospective claims review basis. Conducts the retrospective claims review process which includes a review of both medical documentation and claims data to assure appropriate resource utilization, identification of opportunities for Case Management, identify issues which can be used for education of network providers, identification and resolution of quality issues and inappropriate claim submission. The incumbent utilizes specialized skills and knowledge to achieve successful and measurable outcomes. Monitors and analyzes the delivery of health care services in accordance with claims submitted and analyzes qualitative and quantitative data in developing strategies to improve provider performance and member satisfaction. Identifies potential discrepancies in provider billing practices and intervene for resolution and education or if necessary involve Special Investigation Unit.

Essential Responsibilities:
• Implement the prospective, concurrent and retrospective review processes that are consistent with established industry and corporate standards and are within the Medical Review Clinician's professional discipline.
• Effectively function in accordance with applicable state, federal laws and regulatory compliance.
• Implement all retrospective reviews according to accepted and established criteria (InterQual), as well as other approved guidelines and medical policies.
• Promote quality and efficiency in the delivery of retrospective review services.
• Respect the member's right to privacy, sharing only information relevant to the member's care and within the framework of applicable laws.
• Practice within the scope of ethical principles.
• Identify and refer members whose healthcare outcomes might be enhanced by Case Management or Condition Management interventions.
• Employ collaborative interventions which focus, facilitate, and maximize the member's health care outcomes.
• Identify issues which can be used to educate professional and facility providers and vendors for the purpose of streamlining and improving processes.
• Develop and sustain positive working relationships with internal and external customers.
• Utilize outcomes data to improve ongoing care management services.
• Other duties as assigned or requested.

• 3-5 years of related, progressive experience in a clinical setting
• Graduated from an accredited nursing program
• Active RN license in PA
• Experience with reviewing professional and facility provider claims
• Experience with CPT/HCPCS codes
• Ability to analyze data, measure outcomes, and develop action plans
• Excellent computer and software knowledge and skills
• 1-3 years of UM/QA/Managed Care preferred
• Certification in utilization management or a related field preferred