Utilization Review Nurse

Reporting directly to the Chief Clinical Officer, the Utilization Management Nurse (“UM RN”) is responsible for ensuring timely, high quality, and cost-effective therapeutic care to patients utilizing the TOI model in conjunction with our Mission, Vision, and Core Values.  Your clinical care review determinations for our hematology and oncology patients will be instrumental in assuring patient access to life-saving care and supporting the value-based ideology of the practice.

PRIMARY JOB RESPONSIBILITIES

• Review cases for completeness of supporting documentation
• Conduct pre-authorization review of services to ensure compliance with medical policy and contracts
• With the UM Medical Directors, utilize evidence-based clinical guidelines to make utilization management decisions
• Meet delivery timelines in notifying patients and providers of authorization decisions
• Collaborate with nursing, eligibility, and authorization teams to facilitate continuity of care and optimal patient outcomes
• Maintain accurate documentation of utilization and case management activities and report on those regularly
• Adhere to practice policies and procedures, including compliance with HIPAA privacy and security requirements and all state, federal and plan regulatory mandates
• Participate in quality improvement initiatives to enhance processes and service delivery
• Participate in process improvement/cost of health care initiatives

• Ensure workflow procedures and guidelines are clearly documented and communicated
• Interpret or initiate changes in guidelines/policies/procedures

• Collaborate across functionally to improve member outcomes
• Participate in Regulatory and Internal Audits.

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

• Strong verbal and written communication skills
• Ability to work independently, initiate, and successfully complete tasks
• Problem-solving aptitude and the ability to navigate challenging situations with sensitivity and professionalism
• Excellent analytical and critical thinking skills with attention to detail for decision-making and problem-solving

• Must be actively licensed, in good standing, by the appropriate regulatory body in the applicable state.
• Mastery of computer skills, including Word, Excel, Power Point and applicable electronic medical software programs
• Maintain regular attendance
• Ability to effectively present information and respond to questions

• Three (3) years of experience in utilization management

Fully remote position