RN - Utilization Review and Management
Advanced Medical Reviews - Los Angeles, CA

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We are currently seeking a full-time Registered Nurse to work collaboratively with physicians as a utilization review, quality assurance professional. This individual should be self-directed, assertive, and creative in problem solving. The utilization review nurse works under the direct supervision of an MD. Essential Functions: • Providing Quality Assurance, under the supervision of a medical director, for the independent medical reviews. • Performing Utilization Review & Management services within established clinical, productivity, phone, and URAC standards. • Applying clinical skills and expertise in conjunction with established medical criteria to ensure independent reviews are accurate and complete. • Interacting with the respective medical director, AMR staff, independent physician reviewers, and clients to ensure the delivery of high-quality comprehensive medical reviews • Providing administrative and leadership support to staff as directed. • Serving as subject matter expert on complex medical management issues. • Performing other related projects and duties as assigned. Accountabilities: • Routinely works with minimal guidance and seeks guidance on only the most complex tasks. • Responsible for preparing documentation to provide the utmost quality of reviews. • Responsible for facilitating consistent, sound and defensible medical decisions, according to established coverage guidelines/policies, national industry-standard care guidelines, and current scientific evidence as it applies to each case. • Identify solutions to non-standard requests and problems. • Evaluate and analyze available literature on new and existing technologies to determine safety and effectiveness as it relates to the quality of independent reviews. • Ability to abstract pertinent clinical findings and appropriately apply to corresponding clinical criteria. • Maintain confidentiality of case information. • Coach, provide feedback, and guide others.

Qualifications summary

Required Qualifications: • Graduate of an accredited school of nursing. • Current and unrestricted RN license in any of the 50 states, BSN preferred. • Minimum 3 years of clinical experience in an acute care setting • Minimum 2 years experience in utilization review, utilization management, or quality improvement processes. Demonstrated ability to utilize and apply the general and specialized principles, techniques and methods of utilization review and management. • Excellent verbal and written communication, analytical and interpersonal skills. • Excellent problem identification/problem solving and follow through skills • Ability to organize and prioritize multiple assignments within workload • Ability to both function independently and take independent action, within the scope of job responsibilities, and work collaboratively with interdisciplinary teams Preferred Qualifications: • Knowledge of industry-recognized, national guidelines (Milliman/Interqual/ODG/ACOEM) • Familiarity with URAC,JCAHO, NCQA, HIPAA. • Experience in working with established guideline criteria to decide issues of medical necessity, experimental/investigational, utilization review, quality of care/peer review, disability, level of care/length of stay, billing/coding • Demonstrated knowledge and familiarity in research methodologies and ability to interpret medical literature. • Solid computer skills with word processing, spreadsheets, data base management

Benefits

Start Date: ASAP Location: West Los Angeles Office Hours: Full time or Part-time. Possibility of working remotely part of the time. Must work in the West Los Angeles office at least part of the time. Compensation: Competitive

- includes medical, dental, vision, paid time off, and 401K Send resume: Please include your salary expectations and complete the application online at https://home.eease.adp.com/recruit/?id=915071 Any questions, please contact Sarah Spivey sspivey@admere.com 10780 Santa Monica Blvd, #333 Los Angeles, CA 90025

NursingJobs.com - 18 months ago - save job
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About this company
3 reviews
As an integrated medical review company, Advanced Medical Reviews delivers services to diverse managed care and workers' compensation...