Description Acara Solutions is seeking a Utilization Review Nurse to join our client in Williamsville, NY! *Must be Licensed in NYS* Duration: 6 month contract with possible extension Hourly Rate: $35.00-$38.00/HR Schedule: Monday-Friday, either 8AM to 4PM or 9AM to 5PM, 100% remote
- 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 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, 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. Job RequirementsRequired Skills / Qualifications:
- Associates Degree in Nursing required; Bachelor's degree preferred. Current, active, unrestricted, and licensed registered nurse (RN) required. In lieu of RN licensure, a Physical Therapist would be considered.
- Two (2) years of clinical experience as an RN or Physical Therapist in a varied clinical setting required.
- Previous utilization review or utilization management experience required.
- Previous appeal experience in a managed care organization / familiarity with Medicare (CMS) member appeals beneficial.
- 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.
Preferred Skills / Qualifications:
- Previous work experience in an MRU (medical rehab unit) setting, also known as a Rehab Nurse preferred.
- Previous experience in a managed care setting preferred.
Aleron companies (Acara Solutions, Aleron Shared Resources, Broadleaf Results, Lume Strategies, TalentRise, Viaduct) are Equal Employment Opportunity and Affirmative Action Employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender identity, sexual orientation, national origin, genetic information, sex, age, disability, veteran status, or any other legally protected basis. The Aleron companies welcome and encourage applications from diverse candidates, including people with disabilities. Accommodations are available upon request for applicants taking part in all aspects of the selection process. Applicants for this position must be legally authorized to work in the United States. This position does not meet the employment requirements for individuals with F-1 OPT STEM work authorization status. Apply