Utilization Review Nurse - Remote

About the Role

The Utilization Review Nurse will be responsible for reviewing prior authorization requests, managing medical claims disputes, and coordinating transitions of care. This role requires a deep understanding of governmental policies, clinical guidelines, and internal protocols. By working closely with the interdisciplinary team, the Utilization Review Nurse will help to drive better health outcomes and improve the overall patient experience.

As a Utilization Review Nurse at Martin's Point Health Care, you will be part of a dynamic team that values trust, respect, and continuous learning. The company's mission to transform the healthcare system and create a healthier community is rooted in its core values, which include taking care of oneself and others, helping each other, and having fun.

What You Will Do

• Review prior authorization requests for medical necessity, referring to the Medical Director as needed
• Utilize evidence-based criteria, governmental policies, and internal guidelines for medical necessity reviews
• Manage the review of medical claims disputes, records, and authorizations for billing, coding, and compliance-related issues
• Collaborate with healthcare providers, medical directors, and other stakeholders to promote effective utilization of resources
• Coordinate referrals to Care Management programs as appropriate
• Establish and maintain strong professional relationships with community providers
• Act as a liaison to ensure patients receive the appropriate level of care at the right time and place
• Participate in quality initiatives, committees, work groups, projects, and process improvements
• Assist in the creation and updating of department policies and procedures
• Meet or exceed department quality audit scores and productivity standards

What We Are Looking For

• Current nursing licensure in the United States
• Minimum 2 years of experience in utilization review, case management, or a related field
• Strong knowledge of Excel and electronic health records
• Excellent communication, interpersonal, and problem-solving skills
• Ability to work independently and as part of an interdisciplinary team
• Strong understanding of governmental policies, clinical guidelines, and internal protocols
• Experience with medical claims disputes and billing processes
• Certification in utilization review or case management (preferred)

Nice to Have

• Experience with care management software and electronic health records
• Knowledge of Centers for Medicaid and Medicare regulations
• Certification in a related field, such as nursing informatics or healthcare quality
• Experience working in a remote or virtual environment

Benefits and Perks

• Competitive salary and benefits package
• Opportunity to work with a dynamic and mission-driven organization
• Collaborative and supportive work environment
• Professional development and growth opportunities
• Flexible remote work arrangements
• Comprehensive health insurance and retirement plans
• Generous paid time off and holidays
• Access to cutting-edge technology and tools

• Develop a strong understanding of utilization review principles and practices to stand out in your application.
• Highlight your experience with Excel and electronic health records, as these skills are essential for the role.
• Be prepared to discuss your approach to medical necessity reviews and how you stay current with changing governmental policies and clinical guidelines.
• Showcase your ability to work independently and as part of an interdisciplinary team, as this is critical for success in this position.
• Consider obtaining certification in utilization review or case management to demonstrate your expertise and commitment to the field.
• Research Martin's Point Health Care's mission, values, and culture to demonstrate your alignment with the organization's goals and values.