Utilization Review Nurse; UR RN
Position: Utilization Review Nurse (UR RN)
Location: 100% Remote in the approved states (AR, DC, FL, , IL, KS, LA, MD, MN, MO, MT, NC, ND, NE, NM, OK, SC, SD, TN, TX, UT, VA, WY)
Pay: $40.87 - 44.23/hr. (Depends on relevant experience and location)
Schedule: Day shift | 40 hours weekly between Mon - Fri
Key Responsibilities
ā¢ Identifies Potential Quality Issues (PQIs) by conducting timely reviews of medical records. This includes researching, investigating, analyzing, and preparing case summaries with appropriate recommendations for further actions.
ā¢ Develops peer-review cases and other quality-improvement activities to monitor deviations from accepted standards of care and suggest corrective action plans.
ā¢ Responds to AHRQ concerns and documents a rationale for cases when the facility's position does not concur with the AHRQ position.
ā¢ Requests Practice Pattern Analyses (trend) to assist with identifying physician practice patterns for confirmed severity cases.
ā¢ Identifies and refers cases for focused reviews to Clinical Quality Management Leadership.
ā¢ Performs focused study data collection, reporting, analysis, and makes recommendations for improvement.
ā¢ Refers cases for review as appropriate to Program Integrity, Case Management, Care Coordination, Population Health Improvement, Disease Management, Congressional Relations, Customer Grievances, and other departments.
ā¢ Reviews Potential Quality Issues with Medical Directors when appropriate.
ā¢ Performs other duties as assigned.
Qualifications
ā¢ High School Diploma or GED is required, Bachelor's in Nursing or in a health care field preferred.
ā¢ Active Registered Nurse License.
ā¢ Must have 3 years of clinical experience (medical/surgical, and/or behavioral health).
ā¢ 1 year of experience in Clinical Quality Management required.
ā¢ 1 year of experience with data analysis and reporting required.
ā¢ Experience with Inter Qual criteria or similar criteria sets required.
ā¢ General knowledge of Medicare, TRICARE, or other government healthcare programs required.
ā¢ U.S. Citizenship and able to qualify a Department of Defense (DoD) background check, and Credit check.
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Location: 100% Remote in the approved states (AR, DC, FL, , IL, KS, LA, MD, MN, MO, MT, NC, ND, NE, NM, OK, SC, SD, TN, TX, UT, VA, WY)
Pay: $40.87 - 44.23/hr. (Depends on relevant experience and location)
Schedule: Day shift | 40 hours weekly between Mon - Fri
Key Responsibilities
ā¢ Identifies Potential Quality Issues (PQIs) by conducting timely reviews of medical records. This includes researching, investigating, analyzing, and preparing case summaries with appropriate recommendations for further actions.
ā¢ Develops peer-review cases and other quality-improvement activities to monitor deviations from accepted standards of care and suggest corrective action plans.
ā¢ Responds to AHRQ concerns and documents a rationale for cases when the facility's position does not concur with the AHRQ position.
ā¢ Requests Practice Pattern Analyses (trend) to assist with identifying physician practice patterns for confirmed severity cases.
ā¢ Identifies and refers cases for focused reviews to Clinical Quality Management Leadership.
ā¢ Performs focused study data collection, reporting, analysis, and makes recommendations for improvement.
ā¢ Refers cases for review as appropriate to Program Integrity, Case Management, Care Coordination, Population Health Improvement, Disease Management, Congressional Relations, Customer Grievances, and other departments.
ā¢ Reviews Potential Quality Issues with Medical Directors when appropriate.
ā¢ Performs other duties as assigned.
Qualifications
ā¢ High School Diploma or GED is required, Bachelor's in Nursing or in a health care field preferred.
ā¢ Active Registered Nurse License.
ā¢ Must have 3 years of clinical experience (medical/surgical, and/or behavioral health).
ā¢ 1 year of experience in Clinical Quality Management required.
ā¢ 1 year of experience with data analysis and reporting required.
ā¢ Experience with Inter Qual criteria or similar criteria sets required.
ā¢ General knowledge of Medicare, TRICARE, or other government healthcare programs required.
ā¢ U.S. Citizenship and able to qualify a Department of Defense (DoD) background check, and Credit check.
#J-18808-Ljbffr
Apply Now
Apply Now