Job Title: Utilization Review Nurse (RN/LPN)
Department: Medical Management
Reports To: Manager
Budget Responsibility: None
Level of Authority: Staff Position
We are looking for an experienced part-time Utilization Review Nurse. In this position, you will be responsible for ensuring efficient and cost-effective use of healthcare resources while maintaining high-quality patient care standards and support. Your expertise in utilization management will be instrumental in making evidence-based decisions and optimizing patient outcomes.
Independent Clinics of Washington (ICW) is an alliance of local healthcare providers dedicated to offering Medicaid and Medicare patients high-quality, individualized care, while helping independent practices stay independent. ICW helps local providers build their practices and care for their patients by managing administrative tasks, negotiating rates with plans, cutting red tape for faster claims processing, minimizing authorization requirements, advocating for patients, connecting local providers in a supportive network, and more.
We strive to build an inclusive, supportive work culture and are looking for a new teammate who excels as a collaborator and will contribute to the positive environment.
Key Responsibilities
- Conduct pre-certification of inpatient and outpatient services to ensure compliance with medical policy, member benefits, and contracts
- Utilize evidence-based clinical guidelines to make utilization management decisions.
- Proactively identify at-risk patients in need of case/disease management programs
- Meet delivery timelines in notifying patients and providers of authorization decisions.
- Collaborate with healthcare teams to facilitate continuity of care and optimal patient outcomes.
- Verify all enrollment/eligibility benefits prior to authorizing treatment.
- Maintain accurate documentation of utilization and case management activities.
- Adheres to ICW’s policies and procedures, including compliance with HIPAA privacy and security requirements and all state, federal and plan regulatory mandates.
- Participate in quality improvement initiatives to enhance processes and service delivery.
Required Knowledge, Skills, and Abilities
- Strong verbal and written communication skills
- Ability to work independently, initiate, and successfully complete tasks with minimal supervision.
- Cultural awareness
- Problem-solving aptitude and the ability to navigate challenging situations with sensitivity and professionalism
- Excellent analytical and critical thinking skills for decision-making and problem-solving
- Familiar with the application of Interqual criteria
- Confidence in learning new software platforms
Basic Qualification
- Unrestricted Washington State RN or LPN license required
- Three (3) years of experience in utilization management
Preferred Qualifications
- Previous experience working with a managed care program
- Bilingual
As part of the Medical Management ICW team you will receive:
- Competitive salary and comprehensive benefit package
- Opportunities for professional growth
- Work-life balance with flexible scheduling options
- Fully remote position
Equipment Requirements
Requires use of personal computer compatible with Microsoft Remote Desktop with two monitors, microphone, and camera.
Note
The statements herein are intended to describe the general nature and level of work being performed by employees in this position and are not to be construed as an exhaustive list of responsibilities, duties and skills required of personnel so classified. Furthermore, they do not establish a contract for employment and are subject to change at the discretion of the employer.
Job Type: Part-time
Pay: $43.00 - $54.00 per hour
Expected hours: 20 – 24 per week
Benefits:
- 401(k)
- Dental insurance
- Flexible schedule
- Health insurance
- Paid time off
- Vision insurance
Schedule:
- Day shift
- Monday to Friday
Experience:
- Utilization review: 3 years (Required)
License/Certification:
- Washington State or compact RN or LPN (Required)
Location:
- Washington State (Required)
Work Location: Remote
