Embark on a rewarding career journey as a Remote Utilization Review Nurse – Appeals & Denials Specialist! Are you a highly skilled and compassionate Registered Nurse with a proven track record in healthcare utilization review, appeals, and denials management? Do you thrive in a dynamic, remote work environment and possess a deep understanding of medical criteria, particularly InterQual? If so, we invite you to join our team and make a significant impact on the quality of care for our members.
We are seeking a dedicated and experienced Utilization Review Nurse to provide expert clinical review and support for members within our managed care organization. This remote position offers a fantastic opportunity to utilize your clinical expertise, analytical skills, and strong communication abilities to ensure appropriate and timely authorization of healthcare services. You will play a vital role in navigating the appeals and denials process, advocating for our members, and collaborating with providers and facilities to achieve optimal patient outcomes.
Responsibilities:
- Clinical Review & Authorization:** Conduct comprehensive clinical reviews of medical records to determine the appropriateness and medical necessity of requested or rendered healthcare services. Apply established medical criteria, including InterQual, to make informed authorization decisions in coordination with Medical Directors.
- Appeals & Denials Management:** Manage the full lifecycle of appeals and denials, including gathering supporting documentation, communicating with providers and facilities, and advocating for member benefits. Analyze denial trends to identify areas for improvement in authorization processes.
- Discharge Planning & Coordination:** Proactively participate in discharge planning for members, identifying post-discharge needs, coordinating referrals to appropriate services (e.g., home health, rehabilitation), and ensuring a smooth transition of care.
- Communication & Collaboration:** Maintain clear and professional communication with providers, facilities, members, and internal teams regarding authorization decisions, appeals status, and any other relevant information. Actively participate in administrative and clinical teams to enhance program effectiveness.
- Compliance & Documentation:** Adhere to all regulatory requirements and company policies related to utilization review, appeals, and denials. Maintain accurate and complete documentation of all reviews, communications, and decisions.
- Continuous Learning & Quality Improvement:** Stay up-to-date on changes in medical criteria, regulations, and best practices. Participate in quality improvement initiatives to enhance the efficiency and effectiveness of the utilization review process.
- Remote Work Proficiency:** Effectively manage time and maintain productivity in a remote work environment. Ensure a professional and secure workspace for conducting clinical reviews and communicating with stakeholders.
- Conflict Resolution:** Utilize strong interpersonal skills to effectively negotiate and resolve conflicts with external customers (providers, facilities, members) regarding authorization and denial issues.
Qualifications:
- Licensure:** Must possess a valid Registered Nurse (RN) license in Maryland or Compact RN status.
- Experience:** Minimum of 2 years of experience in utilization review, with a strong focus on appeals and denials management. 1 year of experience with InterQual criteria is essential. 2 years of experience in utilization review is preferred.
- Managed Care Expertise:** Demonstrated experience working within a managed care environment, with a thorough understanding of managed care principles and regulations.
- InterQual Proficiency:** Expert knowledge and practical application of InterQual criteria for medical necessity review.
- Communication Skills:** Excellent verbal and written communication skills, with the ability to effectively interact with diverse audiences, including patients, physicians, facility staff, and management.
- Computer Skills:** Proficient in using computer applications and online systems, including electronic health records (EHRs) and claims processing systems.
- Analytical Skills:** Strong analytical and problem-solving skills, with the ability to interpret medical records and apply clinical criteria to make sound judgments.
- Interpersonal Skills:** Excellent interpersonal skills and a positive attitude, with the ability to build rapport and maintain professional relationships.
- Availability:** Availability to work a flexible schedule, including Monday-Friday, 8-hour days, with the potential for up to 40 hours per week. This is a 13-week contract position with no weekends or holidays.
- Physical Requirements:** Ability to travel to a designated office location in Hanover, MD for equipment pickup.
Compensation & Benefits:
- Pay:** Up to $44.00 per hour.
- Schedule:** Monday to Friday, 8-hour days (up to 40 hours per week).
- Location:** Remote (with occasional travel to Hanover, MD for equipment).
Ready for an Easy Start?
This is a low-stress, high-impact role with excellent rewards. If you are a reliable, detail-oriented, and motivated RN with a passion for patient advocacy, we encourage you to apply! We offer a supportive and collaborative work environment, opportunities for professional growth, and competitive compensation.
Contact: Kayla Walsh - 410-825-6186 #2 - rsiirecruit.com
Keywords: Utilization Review Nurse, Registered Nurse, Remote, InterQual, Managed Care, Insurance, Appeals and Denials, Utilization Review, RN, Healthcare, Clinical Review, Medical Necessity, InterQual Criteria, Appeals, Denials, Patient Advocacy.
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