10 часов назад
Utilization Review Nurse (RN) (Healthcare)
Вакансия из Hirify Global, списка международных tech-компанийДля мэтча и отклика нужен Plus
Мэтч & Сопровод
Для мэтча с этой вакансией нужен Plus
Описание вакансии
Текст:
TL;DR
Utilization Review Nurse (RN) (Healthcare): Conducting utilization management and care coordination reviews for health plan members with an accent on prior authorization, medical necessity, discharge planning, and quality outcomes. Focus on applying MCG guidelines and medical policy, identifying complex cases, coordinating with providers and physician reviewers, and managing escalations during business hours and rotating weekend coverage.
Location: Remote within the United States for candidates residing in the CST or EST time zones. Business hours are weekdays from 9–5 CST, with rotating on-call weekend hours for utilization review cases.
Company
operates a health plan focused on medical policy, utilization management, and member care coordination.
What you will do
- Prepare clinical reviews and recommendations for physician reviewers using clinical guidelines, medical policy, and benefit structures.
- Conduct prior authorization, concurrent, and retrospective utilization management reviews.
- Coordinate discharge planning and care programs while monitoring clinical outcomes and quality of care.
- Gather clinical information from providers and facilities and identify complex, outlier, and long-stay cases.
- Escalate care quality issues and departmental cases, ensuring communication and follow-through to resolution.
- Educate and engage members by phone, document interactions, and collaborate with Medical Directors and clinical staff.
Requirements
- Current, unrestricted Texas nursing license or Compact License required. Include license number(s) and corresponding state(s) on the resume.
- Diploma from an accredited school or college of nursing.
- 1–2 years of health plan utilization management experience using standard practice guidelines.
- 3–5 years of clinical experience in a hospital or ambulatory setting with direct patient care.
- Working knowledge of medical and insurance terminology, CPT/ICD-10, authorizations, digital health programs, and NCQA/URAC standards.
- Must reside in the United States within the CST or EST time zones and be available for rotating weekend on-call coverage.
Nice to have
- Experience with healthcare or managed care appeals.
- Familiarity with Salesforce, HealthCloud, or CareIQ.
- CCM, ACM, or MCG certification.
- Experience in cardiology, pulmonology, women’s health, orthopedics, primary care, pediatrics, or oncology.
Culture & Benefits
- Fully remote work environment with virtual team huddles, one-to-ones, messaging, and check-ins.
- Health, dental, vision, life, and disability insurance.
- Retirement savings plan with company match.
- Generous paid time off and vacation.
- Professional development opportunities.
- Dedicated private workspace and secure handling of company-sensitive documents required.
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