Utilization Review Nurse

Recruitment Manager @ Integrated Resources, Inc | Human Resources Management Location: 100% Remote Schedule: M-F 9:00am to 5:30pm with rotating Saturdays from 7-11am CST, including holiday rotation Job Description This position is fully remote, but candidates need to have an Illinois state RN license Assess and analyze clinical service requests (e.g., surgeries, outpatient therapies, DME) using evidence-based MCP/MCG criteria. Verify member benefits and eligibility Process prior authorization determinations within regulatory timelines Collaborate with multidisciplinary teams Summary Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing clients' members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for Client Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Provides concurrent review and prior authorizations (as needed) according to Client policy for Client members as part of the Utilization Management team. Consults with and refers cases to Client medical directors regularly, as necessary. Complies with required workplace safety standards. Required License/Certification Active, unrestricted IL State Registered Nursing (RN) license in good standing. Required Years of Experience 1-3 years of hospital or medical clinic, utilization review or prior authorization experience Seniority level Associate Employment type Contract Job function Health Care Provider Industries Hospitals and Health Care and Public Health #J-18808-Ljbffr Integrated Resources, Inc ( IRI )