Utilization Review Nurse
: Job Details :

About the Company - Walker Healthforce is known as the dominant force of performance, precision, expertise, and integrity in the healthcare consulting community! As a certified WMBE, we provide end-to-end healthcare IT and clinical solutions to hospitals, health systems, and payer organizations, including Fortune 100 firms nationwide. We are healthcare experts, we're custom not commodity and we've been exceeding expectations for nearly 20 years. Join forces with us to experience unparalleled results today!

About the Role - The ideal candidate will have strong analytical skills and the ability to critically review medical files to determine the appropriateness of services recommended by the provider. RNs will need familiarity with reviewing industry recognized care guidelines, medical policies and/or government regulations to make swift determinations on member files. Those who have worked in a production environment with set deadlines and comfort adhering to quality expectations will excel. This is an exciting opportunity to work with a large east coast health insurance payer for an important incoming mandate.

Responsibilities

• Review and investigate Level 2 Commercial Appeals.
• Assess and analyze UM denial reasons and appeal requests.
• Make sound clinical judgments based on appeal reviews, adhering to regulations and clinical guidelines.
• Present clinical findings and recommendations to committees.
• Navigate multiple systems efficiently to maintain turnaround times.

Qualifications

• Must have a NJ RN License or Compact License
• 3 - 5 years of experience with a background in either Utilization Management, Prior Authorization – Medical Surgical (Inpatient or Outpatient), Complex Case Management w/ exposure to UM, Concurrent or Retrospective Medical Policy Review.
• Health Insurance Payer experience preferred, however will accept Health System UM related experience.
• Familiarity interpreting Milliman Care Guidelines MCG guidelines and CareRadius platform exposure is also desirable.
• May be required to reach out to providers via phone and fax
• Ability to make sound clinical judgements quickly to maintain turnaround time while being accurate.
• Strong computer proficiency with general navigation, typing, copy/paste, etc. Relevant tools include: CareRadius, Outlook, Teams, OneNote, Excel

Pay range and compensation package - Pay range or salary or compensation

Equal Opportunity Statement - We are an Equal Opportunity Employer committed to a culturally diverse workforce. All qualified applicants will receive consideration for employment without regard to race, religion, color, age, sex, national origin, sexual orientation, gender identity, disability status or protected veteran status.

Contact our Recruiting Team today to experience the Walker Healthforce difference!