Utilization Review Nurse Job at Robert Half, Nashville, TN

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  • Robert Half
  • Nashville, TN

Job Description

Job Description

Job Description

Our high end client is currently seeking an experienced Registered Nurse (RN) for a fully remote, contract-based, non-clinical utilization management role. This position calls for meticulous knowledge and practice in inpatient and outpatient medical procedures, excluding radiology and home health. The ideal candidate will exhibit a deep understanding and experience with Medicare Advantage programs. Additionally, you will be expected to proficiently handle pre-certification, prior authorization, and pre-service tasks, often referred to as case management or care management.

Responsibilities:

• Utilize specialized knowledge on Local Coverage Determinations (LCD), National Coverage Determinations (NCD), Milliman Criteria (MCG), and InterQual in guiding decision-making processes. • Execute prior authorizations according to medical necessity and plan coverage guidelines. • Coordinate and perform case management across the continuum of care using a person-focused, Medicare Advantage model. • Manage acuity system operations, ensuring accuracy and completeness of data. • Communicate effectively with healthcare professionals to facilitate patient care. • Administer administrative responsibilities related to patient management and care. • Formulate patient treatment plans based on results from risk identification and analysis.

• Active RN licensure (required)

• Solid background in inpatient and outpatient medical procedures (excluding radiology and home health)

• Medicare Advantage experience (required)

• Familiarity with terminologies such as Local Coverage Determinations (LCD), National Coverage Determinations (NCD), Milliman Criteria (MCG), and InterQual.

• Experience with acuity systems will be an added advantage.

• Excellent communication skills and strong clinical judgement.

We are looking for a dedicated Registered Nurse who is seeking a diverse and challenging role. If your experience aligns with the above requirements and you are enthusiastic about this unique opportunity, we encourage you to apply.

Job Tags

Contract work, Local area, Remote job,

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