Registered Nurse - Utilization Review

Pay:

$45.00 - $51.00 per hour

Job description:Position DetailsPosition:

RN Utilization Management / Utilization ReviewSetting:

100% RemoteSchedule:

5x8-hour daysHours:

8:00 AM 4:30 PM or 9:00 AM 5:30 PM

Pacific TimeWeekend:

Every third weekend rotationTypical Caseload:

Approximately 1:40Equipment:

Laptop, keyboard, and mouse providedRequired QualificationsActive

California RN licenseMinimum

3 years of acute hospital Care Management/Utilization Management experienceRecent hospital-based Utilization Review experience requiredEpic experience required

, with recent use within the last 6 12 monthsInterQual experience requiredStrong

Medicare knowledge requiredExperience determining medical necessity and appropriate level of careImportant: Health plan or medical group UM experience alone does not meet the requirement. Candidates need acute hospital-based Care Management/UM experience.Key ResponsibilitiesPerform concurrent utilization reviews for inpatient, observation, and extended outpatient levels of care.Review admissions and continued stays for medical necessity using

InterQual criteria

.Evaluate clinical documentation to determine appropriate level of care and continued stay.Complete admission, concurrent, continued stay, and retrospective reviews.Collaborate with physicians, Case Management, and multidisciplinary teams regarding utilization and medical necessity.Review patient status and ensure compliance with Medicare and regulatory requirements.Support care coordination and appropriate utilization of healthcare resources.Manage prior authorization and pre-certification activities when applicable.Review clinical information involving ICU, Medical-Surgical, pediatric, and other acute-care populations.Maintain accurate and timely documentation within Epic.Support centralized UM operations across three facilities and rotate assignments based on department needs.Maintain productivity while managing a caseload of approximately 40 reviews/patients.