Job Description

Job Overview

The Utilization Management Nurse Reviewer plays a crucial role in healthcare systems by ensuring that medical services are used efficiently and appropriately. They review medical records, treatment plans, and patient information to determine the necessity and appropriateness of medical procedures, tests, and treatments. Utilization Management Nurse Reviewers collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and maintain quality care.

• Conduct assessments of medical services to validate their appropriateness using established criteria and guidelines, ensuring the medical necessity of treatments (e.g., CMS, Milliman Care Guidelines, InterQual, or health plan specific guidelines/criteria).
• Examine and evaluate patient records to verify the quality of patient care and the necessity of provided services.
• Offer clinical expertise and serve as a clinical reference for non‑clinical staff members.
• Input and manage essential clinical details within various medical management platforms.
• Keep up-to-date with regulatory prerequisites (such as URAC) and state standards for utilization review.
• Apply clinical reasoning to determine the suitable evidence‑based guidelines.
• Foster efficient and high‑quality patient care by effectively communicating with management teams, physicians, and the Medical Director.

Additional Duties

• May provide oversight to the work of the team members.
• Continuously improve processes that facilitate better turnaround time, peer‑to‑peer success rates, and reduce returned reports by clients for clarification, ultimately resulting in higher client satisfaction.
• Responsible for the final approval on cases for release to the client.
• Act as a liaison and coordinate quality issue reports along with all new reviewer reports with the VP of Clinical Operations.

Education & Credentials

Licensed Practical/Vocational Nurse with an active and unrestricted license to practice.

Experience

Minimum 2 years clinical nursing experience is required, with at least one year of previous experience in Utilization Management.

Skills & Competencies

• Strong written and spoken communication.
• Professional communication with physicians and clients.
• Ability to handle multiple tasks and adapt swiftly in a dynamic office setting.
• Excellent organizational sense and attention to detail.
• Problem‑solving skills for complex issues.
• Proficiency with Microsoft Word, Excel, PowerPoint, and Outlook.
• Background in medical or clinical practice through education, training, or professional engagement.

Working Conditions & Physical Demands

Any lifting, bending, traveling, etc. required to do the job duties listed above. Long periods of sitting and computer work.

Work‑from‑Home Technical Requirements

Supply and support your own internet services. Maintaining an uninterrupted internet connection is a requirement of all work‑from‑home positions.

Compensation & Benefits

Salary: $45,000 – $70,000 USD.

Benefits include medical, dental, and vision coverage for you and your family; voluntary life insurance options; hospital indemnity, critical illness, accident indemnity, and pet insurance plans; basic life insurance, short‑term disability, and long‑term disability coverage at no cost; generous paid time off; 401k plan with company match; Apple equipment and a media stipend for remote workspace.

Company Commitment

We are committed to providing fair and competitive compensation that reflects each employee's contributions and performance. We value diversity and strive to create an inclusive environment for all employees.

About Dane Street

Dane Street is a fast‑paced Inc. 500 Company with a high‑performance culture. We process over 200,000 insurance claims annually for leading national and regional Workers' Compensation, Disability, Auto, and Group Health Carriers, Third‑Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.

Job Tags

Similar Jobs