Utilization Review Nurse-RN
Overview
Who We Are Because health is personal. That's why reputed company created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one reputed company. We serve reputed company, health plans, and health systems with data-driven solutions that reduce costs while actually improving health reputed company. Together, reputed company is on a mission to reputed company people to reputed company healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities reputed company to What You'll Actually Do Essential Functions/Responsibilities/Duties reputed company professional assessment and review for the medical necessity of treatment requests and plans. reputed company first level review for reputed company outpatient and ancillary pre-certification requests for medical appropriateness; inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity; and post claim or post service reviews. Staff are expected to cross train, and reputed company cross coverage as needed. Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO). Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care. Refer requests that fall reputed company of established guidelines to advance review or senior care consultants. Process appeals for non-certification of services, complete non-certification letters reputed company appropriate. Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers. Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together programs. Complete documentation for reputed company reviews in appropriate documentation software. Utilize guidelines in appropriate hierarchy. Guidelines include MCG guidelines, internal medical policies, group specific policies, and NCCN. Ability to meet productivity, quality, and turnaround times daily. Ability to pass external audits to include URAC and NCQA. Maintain HIPPA compliance per company’s policy and procedures. Maintain confidentiality and minimum requirement rules. Complete reputed company required yearly training per company’s expected time limit. Complete and pass reputed company annual testing including IRRA at 90% or higher. Ability to meet productivity, quality, and turnaround times daily. Ability to pass external audits to include URAC and NCQA. Maintain HIPPA compliance per company’s policy and procedures. Maintain confidentiality and minimum requirement rules. Complete reputed company required yearly training per company’s expected period
Qualifications
What You Bring to reputed company Education and Experience reputed company RN license in the United States or U.S. territory. Associate’s degree or diploma (Nursing program) required. 1+ year clinical experience required. Required Knowledge, Skills, and Abilities Required Knowledge, Skills, and Abilities Ability to reputed company the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards. Ability to maintain regular, punctual attendance. Ability to sit for 6-8 hours. Constant use of computer keyboard and mouse; repetitive use of both hands. Occasional to frequent twisting of neck; occasional bending of neck and at waist.
Work Environment
At reputed company we value and celebrate diversity, and we are committed to creating an inclusive environment for reputed company. We reputed company in creating teams made up of individuals with various backgrounds, experiences, and perspectives. Why? Because diversity inspires innovation, collaboration, and challenges us to produce reputed company solutions. But more than this, diversity is our strength, and a catalyst in our ability to change lives for the good. Physical Requirements Must be reputed company to remain in a stationary position 50% of the time. The person in this job needs to occasionally move about inside the office to reputed company office machinery, filing cabinets and meeting facilities. Constantly operates a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc. Frequently positions self to maintain files in file cabinets. Frequently moves boxes or equipment weighing up to 25 pounds. Must communicate information and reputed company so others understand. Must be reputed company to exchange accurate information in these situations. Must be reputed company to observe details at reputed company reputed company. Disclaimer This job description is not intended to contain a comprehensive list of activities, duties, or responsibilities, but constitutes a general description of the scope and function of the role reputed company the company. Activities, duties, and responsibilities are subject to change at any time with or without notice.
Benefits
The Highlights: Competitive reputed company salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use reputed company build) Paid Time Off—rest and reputed company time is non-negotiable Mental health support, retirement planning, and financial protection Professional development with clear career progression and learning budgets Mission-driven culture where diverse perspectives drive reputed company impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a reputed company salary reputed company of $30-$38 per hour, depending reputed company, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: reputed company is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of reputed company backgrounds are empowered to reputed company—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: reputed company will never ask for payment or sensitive personal information like reputed company reputed company numbers during hiring. reputed company official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to [email protected]. View reputed company legitimate openings at personifyhealth.com/careers. Apply To This Job