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Utilization Management (UM) Nurse

WFM, Remote
Role: Utilization Management (UM) Nurse
Duration: 11+ Months
Location: WFH –TX, NV, AZ, CA (Remote)
Interview Mode: Video

Job Description
  • Must be comfortable with change environment
  • Fast pace environment
  • Clinical roles - min training - must be solid seasoned Utilization management clinical nurse, navigate computers , self sufficient , solid tech - in terms of software navigation and comp skills
  • Must have dedicated place for work, this is a client facing role so no background noises while working
  • No vacations for 2 mths from start date
  • Working PST hours - shift hrs are 11-7 PM PST , they are open for 10-6 PST also if need be

Position Summary:
The Utilization Management Nurse Reviewer is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making.
The Utilization Management Nurse Reviewer works with healthcare providers to ensure appropriate approval of plan benefits. This is accomplished by reviewing clinical information provided to assess medical necessity and the appropriateness of the treatment setting through the application of appropriate policies and criteria (i.e. Milliman). Case assignments may fall in various areas, such as  concurrent review of inpatient services, discharge planning, retrospective review, and  special needs facilities (SNF), Long Term Acute Care Facilities (LTAC) and Rehabilitation Facilities.

Minimum Qualifications:
  • Current Active and Unrestricted Nursing License required ( Associate Degree, Nursing Diploma  or Bachelor’s degree in Nursing)
  • 3 years combined clinical and utilization management experience in a managed health care plan preferred

Preferred Qualifications:
  • Bachelor’s Degree in Nursing preferred with 3-5 years of clinical experience in Utilization Review
  • Required experience in utilization management to include utilization review, concurrent review, discharge planning, transitional care and Skilled nursing review.
  • Knowledge of Medicaid, Commercial or Medicare  Managed Care programs  and regulations

Experience & Education:
  • Experience using and applying InterQual &  MCG clinical guidelines
  • Comprehensive understanding of standards such as NCQA, URAC, CMS (Medicare/Medicaid) and their application in a managed care setting

Primary Responsibilities:
  • Performs utilization management reviews in accordance with federal and state regulations
  • Maintains compliance with regulatory changes affecting utilization management
  • Perform UM reviews (prospective/concurrent/retrospective) for inpatient services according to the NCQA, URAC, CMA & DOH standards and client requirements and/or policies
  • Reviews UM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer
  • Adheres to Department of Labor, state and UM timeframe requirements per contract
  • Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results
  • Tracks status of all utilization management reviews in progress
  • Releases UM determinations to claim stakeholders following client-established protocols
  • Works closely with management team in the ongoing development and implementation of utilization management programs
  • Certifies reviews that meet clinical review criteria/guidelines
  • Adheres to quality standards and UM guidelines
  • Maintains all required utilization management review documentation in the UM software in a timely manner
  • Refer cases to case management as indicated/appropriate
  • Responds to inbound telephone calls pertaining to UM reviews in a timely manner, following client-established proto
  • Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols
  • Maintains acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives
  • Learns new methods and services as the job requires
  • Advises supervisor of any potential problems as they become evident
  • Manages assigned workload within established performance & productivity standards
  • Attends meetings to achieve departmental goals and objectives
  • Able to work rotational shifts with adherence to schedule a must, including evenings, weekends, holidays and overtime as necessary
  • Performs other projects and duties as assigned
  • Demonstrates a professional demeanor with respect to all communications and professional dress.


Rahul Yadav
(408) 560-3956

http://reqroute.catsone.com/careers/index.php (Click to see MOST Current Openings)

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ReqRoute, Inc is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, disability, military status, national origin or any other characteristic protected under federal, state, or applicable local law. (www.reqroute.com)


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