Utilization Review Nurse

Rising Medical Solutions has an opening for an Utilization Review Nurse, and we want to hear from you! We're a bill review and cost containment company - so what does that mean? Basically we are trying to fix a very broken healthcare system by reducing the cost of healthcare claims through bill review, case management, and utilization review. Our mission is "To protect the health of healthcare" and everyone here at Rising works hard to achieve this goal. So take a look at the job, let us know what you think, and let's start working towards a better future!

**This is a full-time position- 40 hours per week (Must work M-F each day).

Responsibilities

• Perform all aspects of the Utilization Review Process
• Review records and requests for UR, which may arrive via mail, e-mail, fax, or phone
• Utilize evidence-based guidelines to determine if authorization can be given versus having to send the file...

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...

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...