Utilization Nurse

Requisition ID
2017-1673
# of Openings
2
Category
Operations
US-CA-Santa Monica

Overview

Looking to transition away from bedside care? Apply your clinical experience in an administration role? Well come check us out!!!! We are seeking a skilled RN or LPN with experience in utilization, case management, care plan development, clinical documentation, and/or peer review to serve as a Clinical Quality Assurance Coordinator. Someone who is passionate about compliance and quality assurance Monday through Friday and likes having their weekends and evenings free. We truly believe in our service and apparently a lot of insurance companies do as well as we have shown tremendous growth over the last 8 years and are now proud to say that we’re a global company.

Responsibilities

ESSENTIAL DUTIES AND RESPONSIBILITIES TO PERFORM THIS JOB SUCCESSFULLY INCLUDE, BUT ARE NOT LIMITED TO THE FOLLOWING:

  • Performs quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.
  • Ensures clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.
  • Ensures that all client instructions and specifications have been followed and that all questions have been addressed.
  • Ensures each review is supported by clinical citations and references when applicable and verifies that all references cited are current and obtained from reputable medical journals and/or publications.
  • Ensures the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.
  • Ensure that the appropriate board specialty has reviewed the case in compliance with client specifications and/or state mandates and is documented accurately on the case report.
  • Verifies that the peer reviewer has attested to only the fact(s) and that no evidence of reviewer conflict of interest exists.
  • Ensures the provider credentials and signature are adhered to the final report.
  • Identifies any inconsistencies within the report and contacts the Peer Reviewer to obtain clarification, modification or correction as needed.
  • Assists in resolution of customer complaints and quality assurance issues as needed.
  • Ensures all federal ERISA and/or state mandates are adhered to at all times.
  • Provides insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications.
  • Promote effective and efficient utilization of company resources.
  • Participate in various educational and or training activities as required.
  • Perform other duties as assigned.

 

Qualifications

EDUCATION AND/OR EXPERIENCE 

High school diploma or equivalent required. A minimum of two years clinical or related field experience; or equivalent combination of education and experience. Knowledge of the insurance industry preferably claims management relative to one or more of the following categories: workers' compensation, no-fault, liability, and/or disability.

 

QUALIFICATIONS 

  • Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values.
  •  Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers and decimals; Ability to compute rates and percentages.
  • Must be a qualified typist with a minimum of 40 W.P.M
  • Must be able to operate a general computer, fax, copier, scanner, and telephone.
  • Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
  • Must possess excellent skills in English usage, grammar, punctuation and style.
  • Ability to follow instructions and respond to upper managements’ directions accurately.
  • Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.
  • Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
  • Must be able to work independently, prioritize work activities and use time efficiently.
  • Must be able to maintain confidentiality.
  • Must be able to demonstrate and promote a positive team -oriented environment.
  • Must be able to stay focused and concentrate under normal or heavy distractions.
  • Must be able to work well under pressure and or stressful conditions.
  • Must possess the ability to manage change, delays, or unexpected events appropriately.
  • Demonstrates reliability and abides by the company attendance policy.
  • Must maintain a professional and clean appearance at all times consistent with company standards.

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