PRN Utilization Review Nurse Reviewer

Role Overview

The Utilization Review Nurse Reviewer plays an essential role in managing healthcare resources by evaluating medical services to ensure appropriate use and patient care quality. This role involves thorough review of medical documentation, treatment plans, and patient information to confirm the necessity of medical procedures and optimize care delivery in collaboration with healthcare providers, insurers, and patients.

Key Responsibilities

• Evaluate the appropriateness of medical treatments using established guidelines such as CMS, Milliman Care Guidelines, InterQual, or specific health plan criteria.
• Review patient records to assess care quality and service necessity.
• Provide clinical expertise and guidance to non-clinical colleagues.
• Enter and manage clinical data within medical management systems.
• Stay informed on regulatory standards including URAC and applicable state guidelines.
• Apply evidence-based clinical reasoning to make informed decisions on care.
• Maintain effective communication with management, physicians, and medical directors to support high-quality patient care.
• Serve as final approver for case releases to clients and liaise on quality and reviewer reports with senior clinical leadership.
• Oversee team members as needed and contribute to process improvements enhancing turnaround times and client satisfaction.
• Comply with PRN nursing program requirements such as working a minimum number of shifts monthly, including at least one weekend per month, one major holiday, and one minor holiday annually.

Qualifications and Experience

• Unrestricted LVN/RN license obtained through accredited vocational nursing program or college.
• Minimum of two years clinical nursing experience required.
• At least one year of experience in Utilization Management.
• Proficient verbal and written communication skills suitable for professional interactions with physicians and clients.
• Strong multitasking abilities with adaptability in a dynamic work environment.
• Well-developed organizational skills and meticulous attention to detail.
• Ability to resolve complex problems effectively.
• Competent in Microsoft Office applications including Word, Excel, PowerPoint, and Outlook.
• Experience or education in clinical or medical practice.

Working Conditions and Technical Requirements

• Prolonged periods of sitting and extensive computer use.
• Physical requirements may include lifting, bending, and travel as necessary.
• Remote work requires employees to self-provide reliable internet service and maintain stable connectivity.

Compensation and Benefits

Salary is competitive and dependent on experience, education, and relevant skills. Comprehensive benefits include medical, dental, vision insurance; voluntary life, hospital indemnity, critical illness, accident, and pet insurance; employer-provided basic life insurance, short- and long-term disability coverage; generous paid time off; 401(k) with company match; provision of Apple equipment and a media stipend for remote work setup.

Additional Information

The position is offered under a PRN nursing arrangement designed to provide flexible support during peak periods, weekends, and holidays. This opportunity suits professionals aiming to maintain and enhance clinical quality assurance capabilities within a responsive and fast-paced environment.

About Dane Street

Dane Street is a rapidly growing enterprise recognized for its high-performance culture, processing over 200,000 insurance claims annually across a variety of national and regional health-related organizations. The company specializes in Independent Medical Exams and Peer Review programs to assist clients in effective claims management.