Utilization Review RN - Remote

at Guidehouse in Oklahoma City, Oklahoma, United States

Job Description

Job Family :

Clinical Appeals Nurse

Travel Required :


Clearance Required :


What You Will Do:

The Remote Utilization Management Nurse – is accountable for performing initial, concurrent, and/or post-service review activities; discharge care coordination; and assisting with efficiency and quality assurance of medical necessity reviews in alignment with federal, state, plan, and accreditation standards. Serves as a liaison between providers/facilities. This position is 100% remote. Some evening/weekends/holidays required.

General Functions:

+ Experience and knowledge of clinical guidelines/criteria and the accurate application during a clinical review. Maintains objectivity in decision making by utilizing facts to support decisions.

+ Supports the care management model as a working partner with providers, facilities, care managers, social workers, pharmacists, and other professional staff.

+ Able to adhere to communicated utilization management productivity metrics, including call volume and reviews.

+ Able to adhere to quality standards for utilization management per policy, including appropriate documentation in alignment with guidelines, strict adherence to turn around time, identification of deviations from the progression of care, initiation of a discharge plan, and communication of barriers to other team members.

+ Demonstrates a solid understanding of managed care trends, payer regulations, reimbursement, and the effect on utilization and outcomes of the different methods of reimbursement.

+ Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to address utilization/resource and progression of care issues. Assists in developing and implementing an improvement plan to address issues.

+ Implements a discharge plan to prevent avoidable days or delays in discharge.

+ Transition individuals to next level of care in coordination with facility Discharge Planner.

+ Identify and refer complex risk members to care management.

+ Completes documentation in a timely, complete, and accurate manner in accordance with client benefits, guidelines, and regulatory requirements.

+ Identify documents and refer cases to the Physician Advisor for medical review when services do not meet medical necessity criteria, the appropriate level of care, and/or potential quality issues.

+ Utilizes resources efficiently and effectively.

+ Must be proficient in various word processing, spreadsheet, graphics, and database programs, including Microsoft Word, Excel, PowerPoint, Outlook, etc.

+ Attention to detail, strong organizational skills and self-motivated.

+ Ability to independently & accurately make decisions and assimilate multiple data sources or issues related to problem solving.

+ Ability to work under a timeline/deadline & provide clear & accurate updates to project leader of assignment progress, hours worked & expected outcomes daily.

+ Familiarity with medical records assembly & clinical terminology, coding terminology additionally beneficial.

+ Personal responsibility, respect for self and others, innovation through teamwork, dedication to caring and excellence in customer service.

+ Other duties as assigned.

What You Will Need:

+ Graduate of an accredited school of nursing, RN.

+ Current Registered Nurse license in the state of hire.

+ Minimum of 3 years clinical experience.Minimum of 2 years Utilization Management experience.

+ Clinical Denials Experience required

Nice To have:

+ Bachelor’s or master’s degree in Nursing.

+ Health plan based utilization review.

+ California Nursing License


The annual salary range for this position is $73,600.00-$110,500.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training, security clearances, licensure and certifications, and other business and organizational needs.


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Job Posting: JC251927081

Posted On: Dec 02, 2023

Updated On: Dec 13, 2023

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