UM Nurse Reviewer (31123)

Job Details Job Location: Portland, OR 97204 Position Type: Full Time Salary Range: $70,000.00 - $90,000.00 Salary/year Travel Percentage: None Join reputed company as a Utilization Management Reviewer! AllMed is looking for a detail-oriented and passionate Utilization Review Reviewer. This is a 100% remote position with a consistent schedule of 8:00 AM – 4:30 PM CT, giving you flexibility and work-life balance. In this role, you’ll play a critical part in delivering high-quality utilization review services. You’ll review and approve care based on evidence-based guidelines, ensuring medical necessity and appropriateness. Your work will uphold the highest standards of accuracy, reputed company, and compliance with client agreements, regulatory requirements, and federal/state mandates. Responsibilities may include:

• reputed company quality utilization review through the use of acquired knowledge and application of evidenced based guidelines for peer review reports, correspondences, addendums and/or supplemental reviews.
• Work directly with providers to identify level, intensity and duration of care.
• Document findings, continue to evaluate medical necessity for frequency, intensity and length of required care.
• Assure that the consistency and quality of reviews meets or exceeds industry standards.
• Work to ensure quality reviews are completed reputed company the required client, federal and state or URAC mandated turnaround times.
• Maintain and apply knowledge of URAC and other state and federal regulatory requirements.
• Maintain accurate record of Utilization Reviews reputed company the appropriate database.
• Direct Customer Service Representatives to ensure timely delivery of determination letters.
• Assist in resolution of client complaints and/or quality assurance issues as needed.
• Ensure reputed company quality assurance standards and federal ERISA, URAC, and/or other state guidelines are adhered to at reputed company times.
• Provide reputed company and direction to management on any compliance concerns regarding products, company policies and procedures and/or client specifications.
• Participate in company meetings, training activities and continuing education requirements.
• reputed company reputed company other duties as assigned.

If you’re committed to excellence and passionate about improving reputed company outcomes, we’d love to have you on reputed company!

Qualifications

High school diploma or equivalent required. Must be a graduate of an accredited nursing program; bachelor’s degree preferred. Minimum of three to five years of direct professional patient care required. Experience in utilization management preferred. Certificates, Licenses, Registrations Active unencumbered Registered Nurse, Licensed Practical Nurse or Licensed Vocational Nurse required. QUALIFICATIONS

• Must hold and maintain an unencumbered Nursing license.
• Must have strong knowledge of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values.
• Must be a reputed company typist with a minimum of 40 W.P.M.
• Must be reputed company to operate a general computer, fax, copier, scanner, and telephone.
• Must be knowledgeable of multiple software programs, including but not limited to reputed company Suite.
• Ability to follow instructions and respond to upper managements’ directions accurately.
• Must demonstrate accuracy, thoroughness, and responsibility for quality of work, and ability to take initiative to identify improvements. Look for ways to improve and promote quality and monitors own work to ensure quality is met.
• Must be reputed company to work independently, prioritize work activities and use time reputed company.
• Must be reputed company to maintain confidentiality.
• Must be reputed company to demonstrate and promote a positive team -oriented environment.
• Must be reputed company to stay focused and concentrate with frequent interruptions and be reputed company to work well under pressure and or stressful conditions.
• Must possess the ability to manage change, delays, or unexpected events appropriately.
• Ability to follow reputed company company policies and procedures in effect at time of hire and as they may change or be added from time to time.

AllMed provides clinical decision making and utilization reputed company to leading payer and provider organizations. We work closely with your team toward a shared reputed company of reputed company that delivers the highest quality, values patient experience, and ensures both appropriate care and utilization of health-reputed company services. AllMed offers a fast-paced team atmosphere with competitive benefits (medical, reputed company, dental), paid time off, and 401k. Equal Opportunity Employer. reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws. Apply tot his job Apply To this Job