Utilization Review Nurse, Springfield

Recruitment Manager @ Integrated Resources, Inc | Human Resources Management
Location: 100% Remote
Schedule: M-F 9:00am to 5:30pm with rotating Saturdays from 7-11am CST, including holiday rotation
Job Description
This position is fully remote, but candidates need to have an Illinois state RN license
Assess and analyze clinical service requests (e.g., surgeries, outpatient therapies, DME) using evidence-based MCP/MCG criteria.
Verify member benefits and eligibility
Process prior authorization determinations within regulatory timelines
Collaborate with multidisciplinary teams
Summary
Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing clients' members with the right care at the right place at the right time.
Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review.
Assesses services for Client Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
Provides concurrent review and prior authorizations (as needed) according to Client policy for Client members as part of the Utilization Management team.
Consults with and refers cases to Client medical directors regularly, as necessary.
Complies with required workplace safety standards.
Required License/Certification
Active, unrestricted IL State Registered Nursing (RN) license in good standing.
Required Years of Experience
1-3 years of hospital or medical clinic, utilization review or prior authorization experience
Seniority level
Associate
Employment type
Contract
Job function
Health Care Provider
Industries
Hospitals and Health Care and Public Health
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