Utilization Review Nurse

Full-time Bio & Pharmacology & Health

Responsibilities

• Complete medical necessity and level of care reviews for requested services using clinical judgment and evidence-based guidelines
• Utilize Oscar Clinical Guidelines and Milliman Care Guidelines (MCG) to assess care appropriateness
• Obtain necessary clinical information via telephone and fax to assess member conditions
• Meet required decision-making SLAs and ensure compliance with all applicable laws and regulations
• Refer members for further care engagement when necessary

Requirements

• Active, unrestricted US RN licensure or an active compact multistate license
• Associate Degree in Nursing or graduate of an accredited school of nursing/nursing diploma program
• 1+ years of utilization review experience in a managed care setting
• Strong experience utilizing Milliman Care Guidelines (MCG)
• 1+ years of clinical experience, including at least one year...