Utlization Review Nurse RN

Mindlance is a global Talent, Teams, Projects, and Workforce Solutions partner, serving leading enterprises across industries since 1999. With a 5,000 strong footprint across multiple countries, we deliver scalable, AI native solutions that help organizations build, optimize, and transform their workforce.

remote within IL, TX, TN, NM, OK, MT 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