Preservice Review Nurse - Remote
$60,320–$108,160 year
RemoteUnited States
Job Summary
Evaluate and assess provider requests for medical necessity, benefit levels, and contractual status using approved Milliman Care Guidelines. Determine eligibility, approve cases, or send pending items to the medical director based on site of service and product criteria. Maintain 98% accuracy in clinical review case notes and summaries within Facets while adhering to strict turnaround times and regulatory compliance standards including NCQA, CMS, and state Nurse Practice Acts. Precept new staff and serve as a resource for clinical guidance. Requires a current Nevada RN license with 2+ years in critical care, ER, or med-surg. Work Monday through Friday, 8:00 am to 5:00 pm PST, remotely from anywhere in the U.S.
Required Qualifications
- A current, unrestricted RN license for the state of Nevada
- 2+ years of recent critical care, ER and/or med-surg nursing experience
- Proficient with Microsoft Word to create, edit, save and send documents
- Ability to navigate a Windows environment, Microsoft Outlook, and conduct Internet searches
- Must be available to work Monday - Friday from 8:00 am - 5:00 pm PST
- Must be able to work remotely from anywhere within the U.S.
- Candidates are required to pass a drug test before beginning employment
Desired Qualifications
- 2+ years Utilization Management experience in managed care, acute or rehab setting
- Knowledge of utilization review process and prior authorization process in a managed health care industry
- Knowledge of ICD9 / CPT coding and Milliman Care Guidelines
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