Nurse RN 2 (Utilization Review Nurse)
Remote
Duration- 6+ months
 

Day to Day Responsibilities

Performs concurrent reviews for inpatient admissions for members using FEP and  evidenced based guidelines, policies and nationally recognized clinal criteria across FEP’s line of business. Ensures diagnosis matches ICD 10 codes.

Triages and prioritizes cases to meet required, regulatory turn-around times. Expedites access to appropriate care for members with urgent needs using expedited review process.

• Develops determination recommendations. If the recommendation is to deny a specific treatment, presents cases to Medical Director (MD) as required.
• Communicate determinations to providers and/or members to be in compliance with state, federal and accreditation requirements.
• Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
• Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
• Identifies potential Third Party Liability and Coordination of Benefit cases and notifies appropriate internal departments.
• Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
• Provides referrals to Case Management, Disease Management

Required Skills (top 3 non-negotiables)

1.	Minimum 3-5 years Acute Care Experience
2.	Strong Computer Skills related to Windows-based programs and applications
3.	Good Communication Skills

Preferred Skills (nice to have)

Varied clinical background

Previous experience in prior authorization or utilization management preferred.

Disqualifiers/ Dislikes on Resumes:

• Must be a registered Nurse in the State of CA, with an Active Unrestricted License
• Big gaps in employment; must reside in California

Education Requirements

• AS Degree Nursing, BSN preferred

Software Skills Required:

• Proficient with windows-based programs, outlook, Microsoft office. Proficient in navigating multiple windows and screens

Required Certifications

• Active unrestricted California Registered Nurse

 

 


At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $40.00/hr.