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Utilization Review Nurse

75% Flex
Remote: 
Full Remote
Experience: 
Mid-level (2-5 years)
Work from: 
Illinois (USA), United States

Offer summary

Qualifications:

3+ years experience as RN, Registered Nurse in state.

Key responsabilities:

  • Review and evaluate care documentation
  • Collaborate with internal/external teams for clinical resolutions
  • Process and evaluate complex data and information sets
US Tech Solutions logo
US Tech Solutions Human Resources, Staffing & Recruiting Large https://www.ustechsolutions.com/
1001 - 5000 Employees
About US Tech Solutions
Our Talent Your Results - This is the premise behind US Tech Solutions. Our flexible engagement model offers right-fit talent on-demand - when, where and how you need it, so you can achieve your business objectives. We offer contingent, contract-to-hire or direct staffing services. At USTECH, we understand how critical talent is to every organization, as well as how the world of work and the workplace is changing. We offer the most effective means to help you acquire, manage and optimize talent. QUICK FACTS: 3,600+ Active Employees 40+ Global Locations 150+ Clients USTECH was founded in 2000 by Manoj Agarwal. Today, we are a global firm offering talent solutions to 150 customers including 20% of Fortune 500 across Financial Services, Healthcare, Life Sciences, Aerospace, Energy, Retail, Telecom, Technology, Manufacturing, and Engineering. We are headquartered in New Jersey with 40 global locations across the USA, Canada, Europe, and India. To learn more about how US Tech Solutions can help your business be more productive, try before it buys, decrease costs, and increase flexibility, visit our website: www.ustechsolutions.com or email us at info@ustechsolutions.com Awards: Staffing Industry Analyst – ‘Largest Staffing Firms’ in the U.S., 2017, 2016 Staffing Industry Analyst – ‘Fastest growing staffing Firm’, 2017 Staffing Industry Analyst ‘Largest Diversity Firm Award’ KellyOCG Supplier Excellence Award 2016, 2015, 2013, 2012 Deloitte ‘Technology Fast 500’, North America – 2015, 2014, 2013, 2012 Diversity Business ‘Top U.S. Business’ (multiple awards) INC 500 ‘Fasting Growing Firm’ in North America (multiple awards) TAPFIN 100 – ‘Top Diversity Supplier’ Randstad Sourceright Premier Partner – ‘Top 20 Supplier’ across all Randstad MSP Programs Volt Consulting Group ‘Supplier of the Year’ (multiple labor categories)
See more US Tech Solutions offers

Job description

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Your missions

Job Description:
  • Participates in the development and ongoing implementation of QM Work Plan activities.
  • Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives
 
Responsibilities:
  • Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.
  • Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
  • Data gathering requires navigation through multiple system applications.
  • Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
  • Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
  • Responsible for the review and evaluation of clinical information and documentation.
  • Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.
  • Works Potential Quality of Care cases across all lines of business (Commercial and Medicare).
  • Independently coordinates the clinical resolution with internal/external clinician support as required.
  • Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data
  • Prepares and completes QM documents based on interpretation and application of business requirements
  • Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements
  • Assists in the development and implementation of QM projects and activities
  • Accountable for completing and implementation of QM Work Plan Activities
 
Experience:
  • 3+ years of experience as an RN
  • Registered Nurse in state of residence
  • Must have prior authorization utilization experience
  • Experience with Medcompass
 
Skills:
  • MUST HAVE MEDCOMPASS or ASSURECARE exp.
  • MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.
  • MUST HAVE UM experience, inpatient utilization management review.
  • MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.
  • MUST HAVE 6 months of Prior Authorization.
 
Education:
  • Active and unrestricted RN licensure in state of residence
 
Questionnaire:
  • Do you have experience with Medcompass?
  • Do you have experience with Prior Authorization?
  • Do you have experience with Utilization Review?
  • Do you have an Active Registered Nurse License?
 
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.
 
US Tech Solutions is an Equal Opportunity Employer.  All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Required profile

Experience

Level of experience: Mid-level (2-5 years)
Industry :
Human Resources, Staffing & Recruiting
Spoken language(s):
English
Check out the description to know which languages are mandatory.
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