The Utilization Management Nurse Reviewer is a vital contributor to the efficiency and effectiveness of healthcare delivery systems. This role is centered on the meticulous review of medical records, treatment strategies, and patient data to assess the necessity and appropriateness of medical actions, procedures, and tests.

Collaboration is key in this position as the Nurse Reviewer engages with healthcare professionals, insurance entities, and patients alike to enhance healthcare services, manage expenditures, and ensure the preservation of high-quality care. Key responsibilities encompass evaluating medical necessity, coordinating care processes, conducting utilization reviews, formulating care plan recommendations, and adhering to regulatory standards and guidelines. Success in this position demands robust clinical expertise, sharp critical thinking abilities, excellent communication skills, and the capacity to make well-informed decisions regarding patient care strategies.

Our PRN Nursing Program is structured for flexibility, catering to staffing needs during peak periods, weekends, and holidays.

• PRN nurses are expected to work a minimum of one weekend each month, one major holiday, and one minor holiday annually.
• A minimum number of shifts each month will be required to help maintain PRN nurses’ quality assurance skills and familiarity with operational procedures.

Core Responsibilities

• Conduct thorough assessments of medical services to authenticate their appropriateness based on established guidelines and criteria, ensuring the medical necessity of treatments following frameworks such as CMS, Milliman Care Guidelines, or other health plan specifications.
• Review and analyze patient records to validate the quality of care delivered and the necessity of the services provided.
• Provide clinical insight and serve as a resource for non-clinical staff to enhance communication and understanding.
• Document and manage crucial clinical information across diverse medical management systems.
• Stay informed about regulatory requirements and state standards pertaining to utilization review practices.
• Utilize clinical reasoning to apply appropriate evidence-based guidelines effectively.
• Promote efficient, high-quality patient care through effective collaboration with management teams, physicians, and the Medical Director.

Qualifications

• Exceptional communication skills, both written and verbal, with the ability to maintain a professional rapport with physicians and clients.
• Strong multitasking capability and adaptability in a dynamic office environment.
• Excellent organizational skills with a keen focus on detail.
• Proven ability to navigate complex and multifaceted challenges.
• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook).
• A solid background in medical or clinical practice through education, training, or professional experience.
• An active and unrestricted LVN or RN license from an accredited institution.

Additional Responsibilities

• Potentially oversee the activities of team members to support collaborative work.
• Continuously enhance processes to optimize turnaround times and success rates, minimizing client requests for clarifications while boosting client satisfaction.
• Responsible for final approvals on cases before they are released to clients.
• Act as a liaison to coordinate quality-related issue reports and new reviewer reports with the VP of Clinical Operations.

Education and Experience Requirements

• A Licensed Practical/Vocational Nurse with a current unrestricted license to practice.
• A minimum of two years of clinical nursing experience is required.
• At least one year of previous experience in Utilization Management is necessary.

Skills and Competencies

• Demonstrated proficiency in both verbal and written communication, along with strong interpersonal skills.
• A solid understanding of computer operations, especially with Microsoft applications and internet navigation.
• Ability to learn new skills to adapt to changing software and hardware requirements.

Working Environment

• This role may require various physical activities, including lifting, bending, and potential travel, while also involving long periods of seated computer work.

Technical Requirements for Remote Work

• Candidates must provide their own internet service, ensuring a strong and uninterrupted connection for this remote role.

Compensation and Benefits

Starting compensation will reflect the candidate’s experience, education, and skills. In addition to a competitive salary, we offer a comprehensive benefits package, including health insurance, retirement plans, and performance bonuses.

Our Commitment

We are dedicated to providing equitable and competitive compensation that recognizes each employee’s contributions. We embrace diversity and strive to create an inclusive environment for all employees.

Benefits Overview

Join us at Dane Street and access a full suite of benefits focused on your health and well-being. We offer medical, dental, and vision coverage for you and your family, along with optional life insurance for dependents. Additional voluntary benefits include hospital indemnity, critical illness coverage, and pet insurance. Employees receive essential life insurance, short-term, and long-term disability coverage at no cost. Our generous paid time-off policy ensures you have ample opportunity to recharge, while our 401k plan with company matching prepares you for the future. We also provide Apple equipment and a media stipend to support your remote workspace.

About Dane Street

Dane Street is a dynamic, Inc. 500 company known for its high-performance culture, seeking innovative, forward-thinking professionals. We process over 200,000 insurance claims each year for prominent national and regional carriers in Workers’ Compensation, Disability, Auto, and Group Health sectors, assisting our clients in achieving optimal medical determinations as part of their claims management process.