Utilization Review Nurse

The Utilization Management Nurse Reviewer plays a crucial role in healthcare systems by ensuring that medical services are used efficiently and appropriately. They review medical records, treatment plans, and patient information to determine the necessity and appropriateness of medical procedures, tests, and treatments.

Utilization Management Nurse Reviewers collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and maintain quality care. Their responsibilities include assessing medical necessity, coordinating care, conducting utilization reviews, providing recommendations for care plans, and ensuring adherence to regulations and guidelines. This role requires strong clinical knowledge, critical thinking skills, communication abilities, and the ability to make informed decisions regarding patient care pathways.

MAJOR DUTIES & RESPONSIBILITIES

• Conduct...

The Utilization Management Nurse Reviewer plays a crucial role in healthcare systems by ensuring that medical services are used efficiently and appropriately. They review medical records, treatment plans, and patient information to determine the necessity and appropriateness of medical procedures, tests, and treatments.

Utilization Management Nurse Reviewers collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and maintain quality care. Their responsibilities include assessing medical necessity, coordinating care, conducting utilization reviews, providing recommendations for care plans, and ensuring adherence to regulations and guidelines. This role requires strong clinical knowledge, critical thinking skills, communication abilities, and the ability to make informed decisions regarding patient care pathways.

Shift Times:

• 9 am start time
• 11:00am start time
• weekend...

The Utilization Management Nurse Reviewer plays a crucial role in healthcare systems by ensuring that medical services are used efficiently and appropriately. They review medical records, treatment plans, and patient information to determine the necessity and appropriateness of medical procedures, tests, and treatments.

Utilization Management Nurse Reviewers collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and maintain quality care. Their responsibilities include assessing medical necessity, coordinating care, conducting utilization reviews, providing recommendations for care plans, and ensuring adherence to regulations and guidelines. This role requires strong clinical knowledge, critical thinking skills, communication abilities, and the ability to make informed decisions regarding patient care pathways.

Shift Times:

• This will be a night shift - 8pm - 5am....

The Utilization Management Nurse Reviewer plays a crucial role in healthcare systems by ensuring that medical services are used efficiently and appropriately. They review medical records, treatment plans, and patient information to determine the necessity and appropriateness of medical procedures, tests, and treatments.

Utilization Management Nurse Reviewers collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and maintain quality care. Their responsibilities include assessing medical necessity, coordinating care, conducting utilization reviews, providing recommendations for care plans, and ensuring adherence to regulations and guidelines. This role requires strong clinical knowledge, critical thinking skills, communication abilities, and the ability to make informed decisions regarding patient care pathways.

Shift Times:

• 9 am start time
• 11:00am start time
• weekend...

CNSI and Kepro are now Acentra Health! Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the company’s mission, actively engage in problem-solving, and take ownership of your work daily. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Acentra seeks a Utilization Management (UM) Nurse Clinical Reviewer - LPN/RN (Remote U.S.) to join our growing team.

Job Summary:

The purpose of this position is to utilize clinical expertise to review medical records...

Under general supervision of the Director of Case Management, the Utilization Review Nurse provides a clinical review of cases using medical necessity criteria to determine the medical appropriateness of inpatient and outpatient services. Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. Provides ongoing communication with the health plan, clinical providers (HMH Physicians/NPs) and care coordination departments regarding medical necessity for prospective, concurrent, and retrospective reviews. Collaborates as a team to ensure that medical records support the level of services being delivered.

ESSENTIAL JOB FUNCTIONS

Every effort has been made to make this job description as complete as possible.  However, it in no way states or implies that these are the only duties the incumbent will be required to perform.  The omission...