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Utilization Review RN (Remote - Compact/AZ RN License)

Company: Change Healthcare
Location: Saint Paul
Posted on: May 15, 2022

Job Description:

Overview of Position

The position is primarily accountable for performing initial clinical appropriateness review of requests for services that require prior authorization or retrospective review. The review process is performed in accordance with established Client (health plan) protocols/guidelines, benefits, and clinical appropriateness criteria. This position works closely with the Health Services Manager and the Medical Director to evaluate, monitor and assure the appropriateness and medical necessity of selected care for members as it relates to quality, continuity and cost effectiveness. This position works with non-clinical staff as part of the referral and/or authorization process. This position is responsible for managing utilization and, if necessary, discussing utilization of service and standards of patient management.

What will be my duties and responsibilities in this job?

+ Performs initial, concurrent, and/or retrospective review of services that require prior authorization or medical appropriateness review using health plan benefits, clinical appropriateness criteria, or plan guidelines/protocols.

+ Documents clinical appropriateness reviews and care management activities in managed care operating Systems.

+ Facilitates cost effective and quality patient care by effective communication with physicians, providers and members.

+ Maintains knowledge of regulatory requirements (i.e. URAC), and state utilization review standards.

+ Ensures authorized services are performed in the most cost effective appropriate setting.

+ Coordinate discharge planning activities for inpatient level of care services and facilitate referral to care management programs.

+ Participates in case review and/or team meetings with managerial team and Medical Director.

+ Participates in rotational after-hours coverage.

What are the requirements needed for this position?

+ Minimum of 3-5 years of clinical experience

+ One year of care management, utilization management experience, clinical documentation or clinical auditing experience

+ Successful work history in a clinical setting and/or health insurance environment

+ Required: Registered Nurse with an active nursing license to practice in the state of the contracted Client (single state AZ RN license OR a multi-state/compact RN license)

+ Preferred: Bachelor's Degree in Nursing

What other skills/experience would be helpful to have?

+ Knowledge of medical appropriateness criteria such as InterQual -, Milliman Care Guidelines -, or eviCore healthcare.

+ Knowledge of CPT, ICD-10, and/or HCPCS codes or coding experience.

+ Knowledge of precertification and/or medical review processes in a health care payor or third-party environment.

+ Knowledge of URAC or NCQA standards.

What are the working conditions and physical requirements of this job?

+ Office/Home Environment.

+ Office Hours: 10am - 6:30pm CST Monday - Friday.

+ After Hours Rotation.

Join our team today where we are creating a better coordinated, increasingly collaborative, and more efficient healthcare system!

COVID Vaccination Requirements

We remain committed to doing our part to ensure the health, safety, and well-being of our team members and our communities. As such, we require all employees to disclose COVID-19 vaccination status prior to beginning employment and we may require periodic testing for certain roles. In addition, some roles require full COVID-19 vaccination as an essential job function. Change Healthcare adheres to COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance.

Equal Opportunity/Affirmative Action Statement

Change Healthcare is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, genetic information, national origin, disability, or veteran status. To read more about employment discrimination protections under federal law, read EEO is the Law at and the supplemental information at\_EEO\_Supplement\_Final\_JRF\_QA\_508c.pdf.

If you need a reasonable accommodation to assist with your application for employment, please contact us by sending an email to with "Applicant requesting reasonable accommodation" as the subject. Resumes or CVs submitted to this email box will not be accepted.

Click here\_%20English\_formattedESQA508c.pdf to view our pay transparency nondiscrimination policy.

California (US) Residents: By submitting an application to Change Healthcare for consideration of any employment opportunity, you acknowledge that you have read and understood Change Healthcare's Privacy Notice to California Job Applicants Regarding the Collection of Personal Information ( .

Change Healthcare maintains a drug free workplace and conducts pre-employment drug-testing, where applicable, in accordance with federal, state and local laws.

Change Healthcare is an equal opportunity employer. All qualified applicant will reveive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, genetic information, national origin, disability, or veteran status.

Keywords: Change Healthcare, St. Paul , Utilization Review RN (Remote - Compact/AZ RN License), Other , Saint Paul, Minnesota

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