Job Information
Independent Health Utilization Review Nurse in United States
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Overview
The Utilization Review Nurse (URN) performs clinical review to determine the medical necessity of requested services. The URN obtains clinical information and utilizes Independent Health policy and/or applicable clinical criteria to determine medical necessity, and when necessary, will consult with the Associate Medical Director and/or Medical Director for all requests that do not meet criteria or Independent Health policy. The URN will adhere to regulatory and compliance requirements, department productivity and quality metrics and provide exceptional customer service to all internal and external customers.
Qualifications
Associates Degree in Nursing required; Bachelor’s degree preferred. Current, active, unrestricted, and licensed registered nurse (RN) required.
Two (2) years of clinical experience as an RN in a varied clinical setting required.
Previous utilization review experience preferred.
Previous experience in a managed care setting preferred.
Experience following established medical guidelines required.
Clinical knowledge of the health or social work needs for the population served.
Demonstrated ability to identify barriers to a successful care management path.
Ability to interact effectively and professionally with internal and external customers.
Proficient PC Navigational skills required; solid data entry and MS Office skills required.
Excellent critical thinking and time management skills.
Excellent written, verbal, and interpersonal communication skills, with demonstrated ability to provide exceptional customer service to internal and external customers.
Demonstrated transferable knowledge, skill, and ability to complete job duties independently and proficiently. Flexibility in work schedules and assignments required.
Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.
Essential Accountabilities
Provide High Quality, Professional Utilization Management Services: (Medical necessity review for prior authorization, pre-certification, concurrent, as well as pre-claim or retrospective payment review.)
Prompt, courteous, professional and error free in performing utilization management functions.
Available to answer inbound phone calls within required timeframes.
Maintain quality of reviews and documentation by demonstrating sound judgment, excellent analytical and communications skills with attention to detail, utilizing designated criteria and/or Independent Health policy as required.
Complete requests in compliance with designated turnaround time.
Maintain Accurate Records:
Clear documentation of clinical information for medical necessity review of all requests, procedures, admissions, and concurrent review.
Accurate documentation of criteria, Independent Health policy or AMD review in case notes.
Complete and timely follow through for disposition of cases – MD reviews, chart reviews, audits, case management referrals, etc.
Provide Technical and Professional Expertise:
Demonstrate accurate understanding of regulatory and contractual issues for all employer/member groups.
Ability to ascertain and gather appropriate information for completion of inquiry (i.e. medical necessity).
Maintain current level of knowledge of nursing, medical and health trend issues.
Exhibits proactive approach to problem solving and critical thinking skills.
Act as resource for professional information.
Immigration or work visa sponsorship will not be provided for this position
Hiring Compensation Range: $35.50 - $38 hourly
Compensation may vary based on factors including but not limited to skills, education, location and experience.
In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.
As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. Click here (http://www.independenthealth.com/about/careers/additional-eeo-aap-information) for additional EEO/AAP or Reasonable Accommodation information.
Current Associates must apply internally via the Job Hub app.
The Independent Health Family of Companies, headquartered in Buffalo, NY, serves nearly 400,000 members and provides innovative health care products and benefits designed to engage consumers in their health and well-being. Established in 1980, our comprehensive portfolio includes Pharmacy Benefit Dimensions, Reliance Rx, Nova Healthcare Administrators, Care for You and the Independent Health Foundation.
Our culture sets us apart. Our core values drive who we are and the work we do. As a member of our family, you’re part of something special, in your work and in the community.
We understand and appreciate that everyone has unique experiences, perspectives and identities which is why we pledge to create a safe space where all people and ideas are welcomed. We are here to continue learning and to generate important dialog.
We are committed to doing what matters most - reaching out, working together, and caring for our community. A healthy community benefits everyone who lives in it. You too can be part of making difference in the lives of others, together we achieve so much more. Please click here (http://www.independenthealth.com/about/community-report) to view our Community Reports.
Apply today and join us on the journey to a happier, healthier, and more inclusive community.
We are committed to providing reasonable accommodations for qualified individuals with disabilities and disabled veterans. We are a drug-free workplace. An applicant for employment in need of an accommodation to participate in the application and recruitment process should contact Human Resources at: accommodations@independenthealth.com or Human Resources, 511 Farber Lakes Drive, Williamsville, NY 14221.
Please note, we do not accept unsolicited resumes. We do not accept resumes from headhunters, placement agencies, or other suppliers that have not signed a formal agreement with us.