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.
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.
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.
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
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
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.
- includes medical, dental, vision, paid time off, and 401K
Send resume: Please include your salary expectations and complete the application online at
Any questions, please contact
10780 Santa Monica Blvd, #333
Los Angeles, CA 90025
- 2 years ago - save job