Job Summary:

The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources. Applies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. Utilizes clinical criteria and policy keys to complete review. Documents in the medical management information system. Prepares and presents more complex cases for Medical Director Review. Refer cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.

Position: Utilization Clinical Reviewer

Guaranteed hours: 40 hours

Contract: 13 weeks (Contract to Hire)

Facility: Tri-West

REQUIREMENTS:

Active, unrestricted RN license
U.S. Citizen
2+ years clinical experience
2+ years Utilization Management experience.
Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and outlook)
Demonstrates effective verbal and written communication skills

Preferred:

3+ years Medical / Surgical experience
Behavioral Health experience
1 year TriWest or TRICARE experience
Managed Care experience

Location: T-5 TRICARE West Region – Candidate Permanent Must be listed states: -

(AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only) – They’re not accepting other state Candidate.

Job Type: Contract

Pay: $38.00 - $39.00 per hour

Expected hours: 40 per week

Benefits:

401(k)
Dental insurance
Vision insurance

Schedule:

Experience:

Utilization review: 2 years (Required)

License/Certification:

RN state or compact state license (Required)

Work Location: Remote

Pacer Staffing jobs

RN Utilization Management