Utilization Review Nurse (UR RN)

Location: 100% Remote in the approved states (AR, DC, FL, ID, IL, KS, LA, MD, MN, MO, MT, NC, ND, NE, NM, OK, SC, SD, TN, TX, UT, VA, WY)Pay: $40.87 - 44.23/hr. (Depends on relevant experience and location)Schedule: Day shift | 40 hours weekly between Mon - FriKey ResponsibilitiesIdentifies Potential Quality Issues (PQIs) by conducting timely reviews of medical records. This includes researching, investigating, analyzing, and preparing case summaries with appropriate recommendations for further actions.Develops peer-review cases and other quality-improvement activities to monitor deviations from accepted standards of care and suggest corrective action plans.Responds to AHRQ concerns and documents a rationale for cases when the facility's position does not concur with the AHRQ position.Requests Practice Pattern Analyses (trend) to assist with identifying physician practice patterns for confirmed severity cases.Identifies and refers cases for focused reviews to Clinical Quality Management Leadership.Performs focused study data collection, reporting, analysis, and makes recommendations for improvement.Refers cases for review as appropriate to Program Integrity, Case Management, Care Coordination, Population Health Improvement, Disease Management, Congressional Relations, Customer Grievances, and other departments.Reviews Potential Quality Issues with Medical Directors when appropriate.Performs other duties as assigned.QualificationsHigh School Diploma or GED is required, Bachelor's in Nursing or in a health care field preferred.Active Registered Nurse License.Must have 3 years of clinical experience (medical/surgical, and/or behavioral health).1 year of experience in Clinical Quality Management required.1 year of experience with data analysis and reporting required.Experience with InterQual criteria or similar criteria sets required.General knowledge of Medicare, TRICARE, or other government healthcare programs required.U.S. Citizenship and able to qualify a Department of Defense (DoD) background check, and Credit check.#J-18808-Ljbffr