Utilization Review Nurse

Job Description:

Grievance & Appeals

Creates complete appeal records for external appeal reviews, using standardized Independent Review Entity (IRE) forms and including all required documentation.

Creates a detailed case summary in narrative format for each appeal.

Submits cases as directed for each applicable geographic region.

Presents verbal and written case summaries to client's Grievance Team and client Medical Directors.

Completes assignments within client-designated turnaround times.

Job Qualifications:

• Bachelor of Science Nursing (BSN) degree or General Nursing & Midwifery (GNM) Diploma or Basic Bachelor of Science (BSC) in Nursing degree or Associate Nursing Degree or Nursing Diploma
• Holds current and unrestricted US Registered Nurse license
• 3 months clinical experience (480 hours of working experience as a RN)
• Work experience as an active RN license and providing direct patient care
• Clinical setting includes inpatient hospital, outpatient hospital or community clinic
• No state license required
• For CL 10 role USRN + UM, minimum 6 months of UM experience.
• Work experience such as TL, QA, Trainer and Claims are preferred and good to have skills only