UM Nurse Reviewer

AllMed provides clinical decision making and utilization management solutions to leading payer and provider organizations. We work closely with your team toward a shared vision of healthcare that delivers the highest quality, values patient experience, and ensures both appropriate care and utilization of health-related services.

AllMed is looking for a detail-oriented and passionate Utilization Review Reviewer. This is a 100% remote position with a consistent schedule of 8:00 AM – 4:30 PM CT, giving you flexibility and work-life balance. In this role, you’ll play a critical part in delivering high-quality utilization review services. You’ll review and approve care based on evidence-based guidelines, ensuring medical necessity and appropriateness. Your work will uphold the highest standards of accuracy, integrity, and compliance with client agreements, regulatory requirements, and federal/state mandates.

Perform quality utilization review through the use of acquired knowledge and application of evidenced based guidelines for peer review reports, correspondences, addendums and/or supplemental reviews. Work directly with providers to identify level, intensity and duration of care. Document findings, continue to evaluate medical necessity for frequency, intensity and length of required care. Assure that the consistency and quality of reviews meets or exceeds industry standards. Work to ensure quality reviews are completed within the required client, federal and state or URAC mandated turnaround times. Maintain and apply knowledge of URAC and other state and federal regulatory requirements. Maintain accurate record of Utilization Reviews within the appropriate database. Direct Customer Service Representatives to ensure timely delivery of determination letters. Assist in resolution of client complaints and/or quality assurance issues as needed. Ensure all quality assurance standards and federal ERISA, URAC, and/or other state guidelines are adhered to at all times. Provide insight and direction to management on any compliance concerns regarding products, company policies and procedures and/or client specifications. Participate in company meetings, training activities and continuing education requirements. Perform all other duties as assigned.