UTILIZATION REVIEW NURSE

You thrive in a fast-paced environment. You’re curious and have an eye for detail. You strive to exceed expectations, and succeed. You’re excited by the opportunity to join a fast-growing company with unlimited opportunities for growth & competitive benefits. Does this sound like you? If so, Boon-Chapman could be the place for you! Job Responsibilities: As a Utilization Review Nurse, your primary responsibility is to evaluate the medical necessity, appropriateness, and efficiency of healthcare services, ensuring optimal patient outcomes while adhering to payer guidelines. You will conduct prospective, concurrent, and retrospective reviews for various health services, including complex, high-cost procedures such as cancer treatments, hospitalizations, and surgeries. Your role will be pivotal in decision-making processes, including processing approvals, denials, and appeals.

Conduct utilization reviews for pre-certifications, prior authorizations, and continued stay determinations for inpatient and outpatient services, with a focus on high-cost, high-complexity cases such as cancer treatments and surgeries. Apply medical necessity criteria using InterQual , NCQA, or other standardized clinical guidelines to ensure appropriate utilization of services. Work closely with our Medical Director or independent physician reviewers on cases requiring further evaluation or when potential denials are identified, ensuring compliance with established policies and procedures. Review and assess complex clinical cases, including high-dollar hospitalizations, extended surgeries, and specialized oncology treatments. Ensure timely, accurate, and thorough reviews of cases that require a deep understanding of both clinical and payer guidelines. Conduct retrospective reviews to ensure that billed services were appropriate and align with coverage policies. Process and manage clinical appeals, providing rationale for denials and collaborating with the Medical Director for resolution when needed. Participate in denial management by preparing clear, concise, and thorough denial letters and justifications. Engage in effective communication with hospital utilization review departments, physician offices, and members to discuss authorization determinations and provide updates. Serve as a resource for both internal teams and external providers, answering inquiries related to utilization management and care coordination. Identify and refer appropriate plan members for case management, disease management, or other care navigation programs to ensure members receive timely and necessary care. Uphold strict confidentiality standards, maintaining compliance with HIPAA and organizational policies. Ensure that all reviews and communications align with state, federal, and payer-specific regulatory requirements. Performs other duties as assigned.