Utilization Review Nurse

w3r Consulting is an award-winning, best-in-class IT consulting and management company that delivers enterprise solutions at the intersection of innovation and ingenuity. Organizations throughout the healthcare payor, financial services, and professionals and business services sectors turn to w3r for a strategic, IT-fueled advantage that elevates their stature and capabilities in competitive global markets. As a minority-owned business, w3r brings diverse and multifaceted people from across different backgrounds and life experiences to the table, unlocking the power of unique perspectives and inventive ideas to help clients achieve their evolving goals.

Registered Nurse responsible for collaborating with healthcare providers, members, and business partners, to optimize member benefits, evaluate medical necessity and promote effective use of resources. Medical necessity reviews may include: drugs and biologics, inpatient admissions, outpatient services, surgical and diagnostic procedures, home health, durable medical equipment and out of network services. Conduct reviews in compliance with medical policy, member eligibility, benefits, and contracts.

Responsible for the effective and sufficient support of all Utilization Management activities to include review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies and compliance guidelines. Uses an established set of criteria to evaluates and authorize the medical necessity of services. Provide notification of decisions in accordance with compliance guidelines. Coordinate with Medical Directors when services do not meet criteria or require additional review. Participation in staff meetings, regular trainings and other collaborative meetings as appropriate. Works with management team to achieve operational objectives and financial goals. Supports teams across UM Department as needed. Active participation and completion of all required trainings. Maintain Required Licensures. Adherence to regulatory and departmental timeframes for review of requests Meet/exceed department Turn Around time, daily established productivity goals, and service levels Proficient knowledge of policies and procedures, Medicare, HIPPA and NCQA standards; Professional demeanor and the ability to work effectively within a team or independently; Flexible with the ability to shift priorities when required Other duties as required