Utilization Review Nurse, Registered Nurse (RN) for LTSS Waiver, Medicaid

Role Overview

• RN Clinician responsible for utilization management services within the scope of licensure.
• Conducts primary functions of prior authorization, inpatient review, concurrent review, retrospective review, medical director referrals and execution of member/provider approval and/or denial letter.
• Reviews provider requests for services requiring authorization.
• Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• May manage appeals for services denied.
• Responsible for written and/or verbal notification to members and providers.
• Demonstrates proactive anticipatory discharge planning; serves as joint transition of care coordinator with case management and facilitates member care transition.
• Ensures medical director written decision is consistent with criteria (CMS, state, medical policy, clinical criteria).
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Requirements

• Bachelors Degree in Nursing preferred
• Registered Nurse (RN) License (Compact or Virginia) REQUIRED
• 3 years of acute care clinical experience REQUIRED
• Previous Utilization Review highly preferred
• Previous LTSS Waiver OR Medicaid experience highly preferred
• InterQual or Milliman experience preferred
• Knowledge of NCQA preferred.
• Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Benefits

• Medical, Dental, Vision plans
• Adoption, Fertility and Surrogacy Reimbursement up to $10,000
• Paid Time Off and Sick Leave
• Paid Parental & Family Caregiver Leave
• Emergency Backup Care
• Long-Term, Short-Term Disability, and Critical Illness plans
• Life Insurance
• 401k/403B with Employer Match
• Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
• Student Debt Pay Down – $10,000
• Reimbursement for certifications and free access to complete CEUs and professional development
• Pet Insurance
• Legal Resources Plan
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.