Utilization Review Nurse

Requisition ID
2018-2494
# of Openings
1
Category
Operations
Location
US-NJ-Mount Laurel

Overview

The Utilization Review Nurse is responsible for performing quality utilization review services and approving care that is medically necessary and appropriate according to evidenced base guidelines and criteria. As a CPC, the nurse also audits medical files and provides written recommendation as to the proper coding and reimbursement for said file.  

 

RN and CPC Certification required.

 

Responsibilities

 

  • Perform quality utilization review through the use of acquired knowledge and application of evidenced based guidelines for Medical Bill Reviews, TX Plans, IMEs, Peer Review reports, correspondences, addendums and/or supplemental reviews.
  • Works direct with providers to identify level, intensity and duration of care.
  • Documents findings, continues to evaluate medical necessity for frequency, intensity and length of required
  • Assures that the consistency and quality of reviews meets or exceeds industry standards.
  • Works to ensure quality reviews are completed within the required client, federal and state or URAC mandated turnaround times.
  • Maintain and apply knowledge of URAC and other state and federal regulatory requirements.
  • Maintains accurate record of Utilization Reviews within the appropriate database.
  • Ensures all quality assurance standards and federal ERISA, URAC, and/or other state guidelines are adhered to at all times.
  • Perform other duties as assigned.

Qualifications

EDUCATION AND/OR EXPERIENCE

  • Must be a graduate of an accredited nursing program; bachelor’s degree preferred.
  • Minimum of two years of direct professional patient care required.

CERTIFICATES, LICENSES, REGISTRATIONS

  • Active Registered Nurse required.
  • CPC Certification through AAPC required.

QUALIFICATIONS 

  • Must possess excellent skills in English usage, grammar, punctuation and style.
  • Ability to follow instructions and respond to upper managements’ directions accurately.
  • Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.
  • Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
  • Must be able to work independently, prioritize work activities and use time efficiently.
  • Must be able to maintain confidentiality.

 

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