Location: all cities,AK, USA
Position Overview: As a Utilization Review Nurse, your primary responsibility is to evaluate the medical necessity, appropriateness, and efficiency of healthcare services, ensuring optimal patient outcomes while adhering to payer guidelines. You will conduct prospective, concurrent, and retrospective reviews for various health services, including complex, high-cost procedures such as cancer treatments, hospitalizations, and surgeries. Your role will be pivotal in decision-making processes, including processing approvals, denials, and appeals.Key Responsibilities:Conduct utilization reviewsfor pre-certifications, prior authorizations, and continued stay determinationsfor inpatient and outpatient services, with a focus on high-cost,high-complexity cases such as cancer treatments and surgeries.Apply medical necessity criteria using InterQual or other standardizedclinical guidelines to ensure appropriate utilization of services.Work closely with our Medical Director or independent physician reviewers oncases requiring further evaluation or when potential denials are identified,ensuring compliance with established policies and procedures.Review and assess complexclinical cases, including high-dollar hospitalizations, extended surgeries, andspecialized oncology treatments.Ensure timely, accurate, and thorough reviews of cases that require a deepunderstanding of both clinical and payer guidelines.Conduct retrospective reviewsto ensure that billed services were appropriate and align with coveragepolicies.Process and manage clinical appeals, providing rationale for denials andcollaborating with the Medical Director for resolution when needed.Participate in denial management by preparing clear, concise, and thoroughdenial letters and justifications.Engage in effective communication with hospitalutilization review departments, physician offices, and members to discussauthorization determinations and provide updates.Serve as a resource for both internal teams and external providers, answeringinquiries related to utilization management and care coordination.Identify and referappropriate plan members for case management, disease management, or other carenavigation programs to ensure members receive timely and necessary care.Uphold strict confidentiality standards, maintainingcompliance with HIPAA and organizational policies.Ensure that all reviews and communications align with state, federal, andpayer-specific regulatory requirements.Qualifications:Registered Nurse (RN) license in the state of Texas (or compact state licensure).Clinical nursing experience (2-4 years) in a hospital, case management, or utilization management setting.2+ years of Utilization Review experience with specific experience in complex case management, including cancer treatments, high-dollar surgeries, and extended hospitalizations.Strong working knowledge of InterQual criteria, ICD-10, and CPT codes.Familiarity with National Comprehensive Cancer Network guidelines is highly preferred.Proficiency in Microsoft Office and various clinical software systems, with excellent organizational and multitasking skills.Excellent written and verbal communication skills, with an ability to explain complex clinical information clearly to non-clinical stakeholders.Physical Requirements: Prolonged periods sitting ata desk and working on a computer. Ability to report to theoffice as needed. Although this is a remote position, you must maintain abilityto work from the office as needed. The job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.