Utilization Review Nurse

Job not on LinkedIn

🔥 18 hours ago

🇺🇸 United States – Remote

💵 $82k - $88k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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TRISTAR Insurance Group

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1987

💼 Consulting

🏥 Healthcare

📦 Logistics

Consulting • Healthcare • Logistics

TRISTAR Insurance Group is a national third-party administrator (TPA) that provides insurance administration and risk management services to employers, insurers and public entities. Its solutions include property & casualty, workers' compensation, general and auto liability, managed care (bill review, case management, utilization review, nurse triage, pharmacy benefit management), absence and disability management, employee group benefits administration, and risk control and workplace safety services. TRISTAR emphasizes collaborative, technology-enabled and tailored services to transform risk into opportunity for its clients.

📋 Description

• Conduct first-level prospective, concurrent, expedited, and retrospective utilization management reviews • Review inpatient services, outpatient services, surgeries, and ancillary service requests • Evaluate treatment requests and clinical information using state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria • Identify medical necessity and refer cases to a Peer Physician when appropriate • Complete reviews within state jurisdiction and URAC timeframes • Review inpatient length of stay when applicable • Arrange alternative care services and discharge planning • Identify patients with ongoing case management needs and refer claimants to the Case Management team • Identify and review potential safety issues with the Medical Director • Promote cost-effective healthcare through an aligned provider network • Refer cases to Telephonic Case Management and Pharmacy TCM • Coordinate with TCM and Pharmacy TCM on appropriate next steps • Manage determinations within the pharmacy portal • Perform NY PAR in the onboard system according to NY MTG Guidelines • Maintain documentation standards, confidentiality, billing, productivity, time management, and quality assurance requirements • Perform other assigned duties

🎯 Requirements

• Diploma, Associate, bachelor’s degree in nursing, or Master’s level (or higher) degree in a Nursing, Health or Human Services field, or equivalent related experience preferred • A current, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license recognized in the relevant jurisdiction(s) is required • Interstate nurse compact licensure is preferred • May be required to obtain additional licensure based on jurisdictional assignment • CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred • Experience with Workers’ Compensation utilization review • Knowledge of state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria • Knowledge of URAC timeframes and standards • Knowledge of HIPAA and PHI laws and regulations • Ability to meet productivity, time management, quality assurance, billing, and documentation requirements • Ability to perform NY PAR in the onboard system in accordance with NY MTG Guidelines

🏖️ Benefits

• Medical, Dental, Vision Insurance • Life and Disability Insurance • 401(k) Plan • Paid Holidays • Paid Time Off • Referral bonus • Fully remote work arrangement