Description

American Traveler is hiring an experienced RN for a Utilization Review position in a fully remote, managed care setting requiring a minimum of 5 years of acute care nursing experience and proficiency with InterQual criteria.

Details

• Fully remote/work-from-home position within a managed care/health plan environment
• Utilization Management unit focused on outpatient authorization review
• Reviews requests for services, procedures, durable medical supplies, and equipment requiring prior authorization
• Applies medical necessity criteria using InterQual, Johns Hopkins Health Plans medical policies, and line-of-business determination guidelines
• Collaborates with Medical Directors and cross-functional administrative and clinical teams
• Monday–Friday day shift, 8:00 AM–5:00 PM EST; must be logged on and available during these hours

Requirements

• Active MD or Compact RN license currently in hand
• Minimum of 5 years of acute care nursing experience
• Minimum of 2 years of utilization review experience
• Proficiency using InterQual and/or Milliman criteria software systems required
• 1 managed care utilization review experience preferred
• SSN and DOB required for consideration
• 1 professional reference required for consideration

Additional Information

• Reviews medical necessity and site of service using nationally recognized criteria and plan-specific medical policies
• Communicates authorization and denial decisions verbally and in writing to providers, facilities, and members
• Responsible for maintaining clinical knowledge, acceptable documentation standards, and quality benchmarks
• Local candidates are accepted at the same rate as travelers