Utilization Review Nurse

🔥 12 hours ago

🌽 Illinois – Remote

🌽 Illinois – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Rising Medical Solutions

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 1999

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Rising Medical Solutions is a company that provides comprehensive solutions for managing the costs and quality of medical care. Their services include medical bill review, care optimization, provider negotiations, and analytics and technology solutions aimed at reducing medical costs and improving care outcomes. The company also offers Medicare compliance solutions, utilization review, peer review, and a variety of management services tailored to enhance the efficiency and effectiveness of medical claims management. Rising Medical Solutions focuses on delivering optimal care at the right price, using advanced analytics and risk modeling to inform decisions and improve service delivery for clients.

📋 Description

• Perform all aspects of the Utilization Review Process • Review records and requests for utilization review received via mail, email, fax, or phone • Use evidence-based guidelines to determine authorization or refer files for Peer or Physician Review • Write nurse summaries on all utilization review files • Document in Rising's and client databases and send determination letters • Establish collaborative relationships with clients, patients, employers, providers, and attorneys • Track utilization review activity to meet turnaround times • Maintain organized files containing clinical documentation of claim interactions • Apply clinical judgment, careful listening, critical thinking, and assessment skills • Respond to written and telephone inquiries regarding case status • Use a computer and multiple software programs simultaneously

🎯 Requirements

• An Associate's or Bachelor's degree in Nursing • Hold an active and unencumbered RN license in one or more states • 3 to 5 years of clinical practice experience or 2 years of case management and/or UR experience • More than one state license (a plus) • Experience with Workers' Compensation, short-term or long-term disability, or liability claims • Ability to set priorities and work both autonomously and as a team member • Well-developed time-management, organization, and prioritization skills • Excellent analytical skills • Superb oral and written communication • Ability to gather data, compile information, and prepare summary reports • Strong interpersonal and conflict resolution skills • Experience in a fast-paced, multi-faceted environment • Demonstrated persistence and attention to detail • General understanding of CPT and ICD-9/ICD-10 codes and Medicare guidelines • Working knowledge of Microsoft Word, Excel, and Outlook • Ability to remain calm during stressful situations • A customer-service mindset

🏖️ Benefits

• Generous Flexible Time Off (take it when you need it!) • Comprehensive benefit package including health/dental/vision insurance, profit sharing, and 401k matching • Career Growth Opportunities - We often promote from within • Professional Development Reimbursement Program (PDRP) • Elevate program designed to recognize and reward employees for their hard work • Top Workplace recognition in the healthcare industry for 2023 • Company culture and social media resources