Job Description

Job Title: Utilization Review Nurse
Job Location: Bothell, WA
Job Duration: 4 Months (possibility of extension)
Shift: 8am - 5pm CST or 9am - 6pm CST/PST/EST
PayRate: $42/hr.on w2
Job Summary:

• Works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential.
• Client staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

Day to Day Responsibilities:

• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members or providers aProductst evidence based clinical guidelines.
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
• Conducts prior authorization reviews to determine financial responsibility for *** and its members.
• Processes requests within required timelines.
• Refers appropriate prior authorization requests to Medical Directors.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Client Care Model.
• Adheres to UM policies and procedures.

Education:

• Completion of an accredited Registered Nurse (RN).

Required Experience:

• 1-3 years of hospital or medical clinic experience.
• 1+ year Prior Authorization or Utilization Management.

Required License, Certification, Association:

• Active, unrestricted State Registered Nursing (RN) license in good standing.

Required Years of Experience:

• 2+ years Prior Auth, MCO and/or UM Experience preferred.

Required Licensure / Education:

• Active, unrestricted State license in good standing (RN).

Job Tags

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