Utilization Review Nurse Auditor

🔥 53 minutes ago

🏖️ New Jersey – Remote

🏖️ New Jersey – Remote

💵 $33 - $46 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

👻 Ghost score 0%

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ExamWorks

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

Founded 2008

🏥 Healthcare

💼 Consulting

⚖️ Legal

Healthcare • Consulting • Legal

ExamWorks is a leading provider of independent medical examinations and peer reviews, specializing in services such as bill reviews, Medicare compliance, and document management. With a robust portfolio that includes agile development and enterprise platform solutions, ExamWorks ensures efficient workflow enhancements and compliance auditing across healthcare sectors. The company supports a network of physicians and offers customized services for the management of medical records and claims, prioritizing reliability for clients in various communities.

📋 Description

• Perform quality utilization reviews using evidence-based guidelines • Approve medically necessary and appropriate care • Prepare peer review reports, correspondence, addendums, and supplemental reviews • Work directly with providers to identify the level, intensity, and duration of care • Evaluate medical necessity for frequency, intensity, and length of required care • Ensure reviews meet industry quality standards and mandated turnaround times • Maintain knowledge of URAC and state and federal regulatory requirements • Maintain accurate utilization review records in the appropriate database • Direct Customer Service Representatives to ensure timely delivery of determination letters • Assist with client complaints and quality assurance issues • Ensure compliance with ERISA, URAC, and other applicable guidelines • Provide management with insight on compliance concerns • Participate in company meetings, training activities, and continuing education • Perform other assigned duties

🎯 Requirements

• High school diploma or equivalent required • Graduate of an accredited nursing program • Active unencumbered Registered Nurse, Licensed Practical Nurse, or Licensed Vocational Nurse required • Current coding certification in OASIS, RAC-CT, CCS, CPC, RHIT, or RHIA required • CPMA certification preferred • Three to five years of direct professional patient care required • Experience in utilization management preferred • Strong knowledge of medical terminology, anatomy and physiology, treatment protocols, medications, and laboratory values • Qualified typist with a minimum of 40 W.P.M. • Ability to operate a general computer, fax, copier, scanner, and telephone • Knowledge of Microsoft Suite and multiple software programs • Ability to maintain confidentiality • Ability to work independently, prioritize work, and use time efficiently • Ability to work under pressure and manage interruptions or unexpected events • Ability to follow company policies and procedures

🏖️ Benefits

• Medical insurance • Vision insurance • Dental insurance • Paid time off • 401k • Continuing education requirements • Company meetings and training activities • Fully remote work • Competitive benefits