Job Description

Role Summary:

The Utilization Review RN Case Manager works collaboratively to ensure quality care and cost-effective outcomes, promoting the physical, psychosocial, and vocational health of plan participants. This role adheres to industry standards and regulatory requirements.

Daily Responsibilities:

Conduct utilization reviews including inpatient and outpatient, admission, discharge planning, retrospective and readmission reviews.
Screen and identify large case management opportunities and communicate effectively with stakeholders.
Develop, review, and implement quality improvement programs and protocols as directed.
Coordinate medical information with large case and disease management teams.
Ensure compliance with URAC requirements and documentation standards.
Provide customer service support, completing requests and interactions promptly and accurately.
Maintain positive and proactive communication with internal and external stakeholders.
Additional Responsibilities:

Complete orientation and training on policies, procedures, and URAC UM Standards.
Supervise non-clinical administrative staff activities related to UR functions.
Utilize software and systems provided for daily duties.
Uphold confidentiality and participate in ongoing training programs.
Qualifications:

Registered Nurse with at least 5 years of clinical nursing experience.
Bachelor's degree and/or certification in UR, Case Management, or related field preferred.
Strong written and oral communication skills.
Positive, proactive team-oriented attitude.
Proficiency in computer skills and software applications.
Active, unrestricted RN license in a U.S. state or territory.
Other Details:

Position: Remote - Work from home
Hours: 9am-6pm EST Monday-Friday, with one late day per month and occasional compensated on-call.
Required occasional in-person training in Nashville.
Experience in oncology preferred.
Equal Employment Opportunity Employer.
Employment Type: Full-Time
Salary: $ 36.00 Per Hour

Job Tags

Hourly pay, Full time, Monday to Friday,

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