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Location

West Palm Beach, FL | United States

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Job description

We are a leading healthcare organization committed to optimizing patient care, controlling costs, and ensuring quality healthcare delivery. Our team of dedicated professionals collaborates with healthcare providers, insurance companies, and patients to make a positive impact on the healthcare system. Join us in our mission to provide efficient, patient-centric, and high-quality healthcare services.

Role Overview:

As a Utilization Management Nurse Reviewer, you will play a pivotal role in ensuring the efficiency and appropriateness of medical services. Collaborating with healthcare stakeholders, you will be responsible for reviewing medical records, treatment plans, and patient information. Your role involves assessing the necessity and appropriateness of medical procedures, tests, and treatments, contributing to the optimization of healthcare delivery.

Key Responsibilities:

Conduct comprehensive assessments of medical services using established criteria and guidelines to validate their appropriateness and medical necessity.
Evaluate patient records to ensure the quality of patient care and the necessity of provided services.
Provide clinical expertise and serve as a reference for non-clinical staff.
Input and manage essential clinical details within various medical management platforms.
Stay updated with regulatory requirements and state standards for utilization review.
Apply clinical reasoning to determine suitable evidence-based guidelines.
Foster efficient and high-quality patient care through effective communication with management teams, physicians, and the Medical Director.
Major Duties & Responsibilities:

Validate appropriateness of medical services using established criteria and guidelines.
Verify the quality of patient care and the necessity of provided services through patient record examination.
Serve as a clinical reference for non-clinical staff members.
Input and manage essential clinical details within medical management platforms.
Stay up-to-date with regulatory prerequisites and state standards for utilization review.
Apply clinical reasoning to determine suitable evidence-based guidelines.
Communicate effectively with management teams, physicians, and the Medical Director to foster efficient and high-quality patient care.
Requirements:

Proficient in both written and spoken communication.
Capable of maintaining professional communication with physicians and clients.
Skilled at handling multiple tasks and adapting swiftly in a dynamic office setting.
Possesses a keen organizational sense and pays close attention to details.
Adept at resolving intricate and multifaceted problems.
Experienced with Microsoft tools such as Word, Excel, PowerPoint, and Outlook.
Background in medical or clinical practice through education, training, or professional engagement.
Holds an unrestricted LVN/RN license from an accredited vocational nursing program (for LVNs) or a nursing degree from an accredited college (for RNs).
Additional Duties:

May provide oversight to the work of team members.
Continuously improves processes to facilitate better turnaround time and client satisfaction.
Responsible for the final approval of cases for release to the client.
Acts as a liaison and coordinates quality issue reports with the VP of Clinical Operations.
Education/Credentials:

Licensed Practical/Vocational Nurse with an active and unrestricted license to practice.
Job Relevant Experience:

Minimum of 2 years of clinical nursing experience required.
One year of previous experience in Utilization Management is preferred.
Job-Related Skills/Competencies:

Strong abilities in both spoken and written communication.
Effective interpersonal skills.
Proficient understanding of computer operations, including Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows.
Capability to acquire new skills and competencies to address evolving requirements.
Working Conditions/Physical Demands:

Any lifting, bending, traveling, etc. required to perform job duties.
Long periods of sitting and computer work.
Work From Home Technical Requirements:

Supply and support your own internet services.
Maintaining an uninterrupted internet connection is a requirement for all work-from-home positions.
Benefits:

We offer generous Paid Time Off, an excellent benefits package, and a competitive salary. Apple equipment and a media stipend are provided for remote workspaces. Join us in an exciting, fast-paced environment where you can make meaningful contributions to the healthcare industry. Apply now and be a part of our dedicated team!
Employment Type: Full-Time
Salary: $ 194,627.00 Per Year

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Job tags

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