To support a mission-driven health organization, the full-time Utilization Review Nurse - RN will conduct medical necessity reviews, escalate non-certifications for secondary clinical review, and analyze clinical records to ensure timely and compliant care determinations. Key responsibilities Conduct medical-necessity reviews to evaluate services against benefit language and medical policy Escalate non-certifications to the Medical Director, ensuring timely and defensible adverse determinations Analyze clinical documentation for completeness and manage a caseload based on urgency and member impact Required qualifications Current, unrestricted RN license in the United States or a U.S. territory Graduate of an accredited nursing program (ADN or diploma required; BSN preferred) 1-2+ years of recent clinical experience in acute care, med-surg, ICU/ED, or similar settings Utilization review or utilization management experience preferred Proficiency with Microsoft Word, Excel, and Outlook, along with knowledge of ICD-10, CPT, and HCPCS coding
...address complex finance and accounting challenges through scalable managed services solutions. Leveraging Deloittes industry experience,... ...-Report managed services offering in the Technology, Media & Telecom Industry. Youll lead client solutions and sales pursuits, advise...
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...AdventHealth Night Shift Call Center Representative Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is...