Utilization Review Nurse

🔥 3 hours ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 10%

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WVU Medicine

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

WVU Medicine is a comprehensive health system affiliated with West Virginia University, providing medical services through a network of hospitals across West Virginia. The system includes notable facilities such as J. W. Ruby Memorial Hospital, WVU Medicine Children's, and various other regional medical centers. WVU Medicine offers a wide range of healthcare services, including specialized and advanced medical treatments such as robotic heart surgery. It's also involved in medical education, research, and community health initiatives, emphasizing a mission of delivering high-quality care to the communities it serves.

📋 Description

• Collaborate with the Medical Director to decrease care variance and ensure timely discharges • Refer members to other plan resources to meet their care conditions • Report to the Health Plan Manager of Utilization Management • Serve as an integral member and collaborative contributor of the health plan’s medical management team • Assist with building and implementing care management review processes, including Prior Authorization, Predetermination, Concurrent Reviews, and Retrospective Reviews • Implement care management reviews according to established criteria, clinical guidelines, and policies • Ensure collaborative interventions focused on maximizing members’ healthcare outcomes • Understand and support the Peer-to-Peer Review process with Medical Directors • Educate internal and external stakeholders and partners • Collaborate with the medical management team to identify members who may benefit from coaching or case management interventions • Understand collected data and work with team members to improve outcomes • Pursue continuous learning and process improvement across Utilization Management

🎯 Requirements

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC) • Three (3) years of healthcare clinical experience • Working knowledge of InterQual and/or Milliman Care Guidelines • Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning • Excellent written and oral communication • Problem solving capabilities to drive improved efficiencies and customer satisfaction • Attention to detail • Proficiency with Microsoft Office • Occasional weekend and holiday work may be required • Preferred: Bachelor's Degree in Nursing or Associate of Science in Nursing Degree (ASN); currently enrolled in a BSN program and BSN completion within three (3) years of hire • Preferred: Medical Management experience for Medicare and/or Medicaid populations • Preferred: Utilization Management experience

🏖️ Benefits

• Full-time, 40 scheduled weekly hours • Exempt status • Remote work location • Occasional weekend and holiday work may be required