Utilization Review Nurse

At Leave Your Mark we help organizations develop, cultivate, operate and ensure success of their people. We’re committed to aligning your organization’s culture and goals with each candidate’s purpose and passions. Through a consultative and individualized talent approach, we are able to create a seamless synergy between clients and candidates leading to collective success for all.

The Utilization Review Nurse (URN) performs clinical review to determine the medical necessity of requested services. The URN obtains clinical information and utilizes applicable clinical criteria to determine medical necessity, and when necessary, will consult with the Associate Medical Director and/or Medical Director for all requests that do not meet criteria for the client's policy. The URN will adhere to regulatory and compliance requirements, department productivity and quality metrics and provide exceptional customer service to all internal and external customers.

Provide high quality, professional utilization management services: medical necessity review for prior authorization, pre-certification, concurrent, as well as pre-claim or retrospective payment review. Maintain accurate records. Provide technical and professional expertise by demonstrating accurate understanding of regulatory and contractual issues for all employer/member groups.