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Utilization Review Nurse I (TN)
Ref No.: 20-01959
Location: Nashville, Tennessee
Title: Utilization Review Nurse
Address: Remote
Contract: 04/06/2020 – 08/30/2020
Hours: Monday – Friday, 8am – 5pm
Pay: $30.00-$40.00/ hour
The Utilization Management Review Nurse is responsible for assuring health care services are available to *** Medicare members in an appropriate cost-effective manner and delivery of those services to promote healthy outcome.

  • Responsible for the effective and sufficient support of all utilization management activities to include prospective concurrent/continued stay review of inpatient medical services for medical necessity and appropriateness of setting according to established policies
  • Collecting, analyzing, and evaluating clinical documentation received using established criteria to determine appropriateness of clinical decisions
  • Adherence to all regulatory and departmental requirements in performing medical necessity reviews
  • Uses clinical knowledge, to analyze clinical data and apply evidence-based criteria to determine the medical necessity of a treatment or service
  • Process approval and adverse clinical determination correspondence for members related to prospective request for services
  • Perform clinical reviews with focus on improved medical outcomes
  • Interact and participant with multiple members of the healthcare team both internally and externally
  • Interact with the Medical Director when unable to approve a request
  • Ability to navigate multiple systems and applications
  • Ability to review benefit plans, and additional clinical resources in order to properly evaluate services being requested
  • Working knowledge of current health care practices and appropriate treatments
  • Perform telephonic outreach to providers and members for additional information or completion of requested services
  • Coordinate appropriate referrals to Case Management and/or other *** programs or services as required

  • Must have reliable internet connection and experience working in a remote setting
  • Excellent interpersonal and communications skills with peers, nursing staff, physicians, nurse practitioners and other health workers involved in the care of a member
  • Ability to maintain and manage daily caseloads, and effectively adapt/respond to complex, fast-paced, rapidly growing, and results-oriented environments
  • Excellent communication and interpersonal skills
  • Strong time management and organization skills
  • Strong research and analytical skills
  • Able to work in a dynamic, fast-paced team environment and to promote team concepts
  • Utilization Management Experience highly preferred

  • Registered Nurse required with 1-3 years’ experience in: Managed Care environment and/or recent experience in an acute-care environment and/or recent experience in utilization management position