[Hiring] Utilization Review Nurse RN @Personify Health

Role Description We are seeking a Utilization Review Nurse RN to join our team on a part-time basis, working a minimum of 28 hours per week. The Utilization Review Nurse will provide professional assessments and review for the medical necessity of treatment requests and plans. The standard operating hours are Monday through Friday, 800 AM–500 PM Pacific Standard Time, weekend availability is required. What You'll Actually Do

• Provide professional assessment and review for the medical necessity of treatment requests and plans.
• Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity; and post claim or post service reviews.
• Cross train and provide cross coverage as needed.
• Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO).
• Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care.
• Refer requests that fall outside of established guidelines to advance review or senior care consultants.
• Process appeals for non-certification of services, complete non-certification letters when appropriate.
• Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers.
• Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together programs.
• Complete documentation for all reviews in appropriate documentation software.
• Utilize guidelines in appropriate hierarchy, including MCG guidelines, internal medical policies, group specific policies, and NCCN.
• Meet productivity, quality, and turnaround times daily.
• Pass external audits to include URAC and NCQA.
• Maintain HIPAA compliance per company’s policy and procedures.
• Maintain confidentiality and minimum requirement rules.
• Complete all required yearly training per company’s expected time limit.
• Complete and pass all annual testing including IRRA at 90% or higher.

Qualifications

• Current RN license in the United States or U.S. territory.
• Associate’s degree or diploma (Nursing program) required.
• 1+ year clinical experience required.

Requirements

• Strong technical proficiency, independent work capability, and effective communication skills.
• Ability to perform essential job functions safely and successfully with or without reasonable accommodation.
• Ability to maintain regular, punctual attendance.
• Ability to sit for 6-8 hours.
• Constant use of computer keyboard and mouse; repetitive use of both hands.
• Occasional to frequent twisting of neck; occasional bending of neck and at waist.
• Must be able to remain in a stationary position 50% of the time.
• Occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities.
• Constantly operate a computer and other office productivity machinery.
• Frequently position self to maintain files in file cabinets.
• Frequently move boxes or equipment weighing up to 25 pounds.
• Must communicate information and ideas so others understand.
• Must be able to observe details at close range.

Benefits

• Part-time schedule designed around your availability and life priorities.
• Access to learning and development opportunities alongside full-time colleagues.
• Mentorship and skill-building that translates to career advancement.
• Competitive hourly compensation that values your expertise.
• Technology and equipment support to set you up for success.
• Base salary range of $30-$38 per hour, depending on location, skills, and experience.
• Part-time employees are not eligible for health benefits. Apply To This Job

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