Sr. Virtual Utilization Review Specialist
$67,912–$91,312 year
RemoteUnited States
Job Summary
Utilize proactive triggers to identify potential over or under utilization of services and initiate referrals to physician advisors. Conduct medical necessity reviews for all admissions, including inpatient and observation clinical reviews for commercial carriers, within one business day of admission. Coordinate the P2P process with physicians, the financial clearance center, and revenue cycle teams to manage denials and minimize denial rates. Prioritize patient reviews based on situational analysis, functional assessment, and medical record review while maintaining communication with in-house care managers. Collaborate with the interdisciplinary team to clarify information, obtain documentation, and educate regarding appropriate levels of care. Comply with FCC and department policies, including confidentiality and patient rights, while actively participating in departmental process improvement teams. This remote role operates 7 days per week from 8:00 a.m. to 10:00 p.m. EST.
Required Qualifications
- Current unrestricted LPN or RN license
- RN compact license preferred
- Bachelor's Degree or equivalent experience
- Specialty/Major: Nursing or related field
- Three years nursing experience in an acute care environment
- Utilization review/discharge planning experience
- Recent experience or working knowledge of medical necessity review criteria
- Current working knowledge of quality improvement processes
- High speed internet access
- Excellent interpersonal, communication and negotiation skills
- Strong clinical assessment, organization and problem-solving skills
- Ability to assess and identify appropriate resources, internal and community
- Ability to prioritize, organize information, and complete multiple tasks effectively in a fast-paced environment
- Resourceful and able to work independently
- Must be inquisitive and demonstrate openness to innovation including AI
- Willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require
- Must be available for weekend shifts
- Must be available for work within scheduled hours from 8:00 a.m. to 10:00 p.m. EST
Desired Qualifications
- RN compact license preferred
- Three years nursing experience in an acute care environment preferred
- Utilization review/discharge planning experience preferred
- Recent experience or working knowledge of medical necessity review criteria preferred
- Current working knowledge of quality improvement processes
- Bachelor's Degree or equivalent experience
- Specialty/Major: Nursing or related field
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