Job Description
As a Utilization Review Nurse, you will ensure the quality and continuity of care for our members by reviewing acuity levels, resource consumption, length of stay, and discharge planning. You will work closely with Medical Affairs and Medical Directors to discuss member care and provide necessary education to healthcare providers on utilization processes.
ResponsibilitiesReview quality and continuity of care by assessing acuity levels, resource consumption, length of stay, and discharge planning.Collaborate with Medical Affairs and Medical Directors to discuss and improve member care.Document and maintain concurrent review findings, discharge plans, and actions taken in health management systems according to utilization management policies.Approve medical determinations or provide recommendations based on requested services and concurrent review findings.Educate providers on utilization processes to ensure high-quality, appropriate care.Provide feedback to leadership on opportunities to improve care levels and medical necessity based on clinical policies.Review members' transfer or discharge plans to ensure timely transitions between care levels and facilities.Collaborate with care management on member referrals as appropriate.Perform other duties as assigned and comply with all policies and standards.Essential SkillsExperience as a Utilization Review Nurse.Proficiency in medical record review and prior authorization processes.Knowledge of Medicare and Medicaid regulations.Strong understanding of utilization management, case management, clinical review, and care management.Graduate from an Accredited School of Nursing or a bachelor's degree in nursing with 2-4 years of related experience.Proficiency with software platforms including TruCare, Interqual, and Microsoft Office, particularly Excel.State Licensure as a Licensed Practical Nurse (LPN).Acute care experience (ICU, med surg) and compact license.Ability to multitask, stay organized, and perform in a fast-paced environment.Clinical knowledge to determine overall health needs and appropriate care levels.Additional Skills & QualificationsUM experience is teachable and not mandatory.General typing skills.Work Environment
This is a fully remote position with working hours from Monday to Friday, 8 AM to 5 PM, accommodating any time zone. Day-to-day responsibilities include managing facilities for acute care inpatient stays, conducting initial reviews, concurrent stay reviews, and discharge planning. The role requires significant collaboration, prioritization of tasks, and independent work, while still being a team player. Productivity metrics include the number of authorizations completed per day and weighted productivity for specific tasks. The role involves high-pressure turnaround times, with some authorizations needing completion within 24 hours. Training includes a 4-week program with learning and development, IT training, compliance training, and ongoing support from a preceptor.
Pay and Benefits
The pay range for this position is $35.00 - $36.00/hr.
Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: • Medical, dental & vision• Critical Illness, Accident, and Hospital• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available• Life Insurance (Voluntary Life & AD&D for the employee and dependents)• Short and long-term disability• Health Spending Account (HSA)• Transportation benefits• Employee Assistance Program• Time Off/Leave (PTO, Vacation or Sick Leave)
Workplace Type
This is a fully remote position.
Application Deadline
This position is anticipated to close on Feb 12, 2025.
About Actalent
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
Diversity, Equity & InclusionAt Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:
Hiring diverse talent Maintaining an inclusive environment through persistent self-reflection Building a culture of care, engagement, and recognition with clear outcomes Ensuring growth opportunities for our peopleThe company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.