Utilization Review - Managed Care Nurse

  • 432531
  • Registered Nurse
  • March 15, 2019
  • 4 Hamilton Landing Suite 100
  • Novato, CA 94949
  • 8 D
  • 13 Weeks
  • May 09, 2019
  • NursesRx
  • Temporary
  • $1,774 - $1,955*
  • *Estimate of weekly payments is intended for informational purposes and includes hourly wages, as well as reimbursements for meal & incidental expenses and housing expenses incurred on behalf of the Company. Please speak with your Recruiter for additional details.

Job Description & Requirements

Utilization Review - Managed Care Nurse

Principle Accountabilities *Review routine referral/service requests on assigned patients in accordance with NCQA timeliness standards and health plan benefit structure. *Prepares and presents cases for medical director review in a concise, objective and organized manner. * Assists with identifying patterns and trends and develops and implements corrective actions when necessary. *Educates and supports members in the accessing care using their HMO and Medicare Advantage benefits as needed. * Review routine referral/service requests on assigned patients in accordance with NCQA timeliness standards and health plan benefit structure. * Identifies and refers patients to disease management, wellness programs and community resources whenever relevant. *Assesses members’ physical, psychological, social, environmental, financial and functional status as necessary and informs the patient’s treating physician of clinically relevant findings e.g. positive score of depression screening, non-compliance with the plan of care and barriers t treatment. *Collaborates with the concurrent review.

Required Qualifications

CA RN LIC Must have Utilization Review Experience This position coordinates utilization review and case management activities for commercial and Medicare enrollees. The Utilization review nurse is knowledgeable about the Nurse Practice Act, NCQA, Millman Care Guides, and the Center for Medicare and Medicaid, HMO timeliness rules and pertinent state and federal regulations.

Preferred Qualifications

Experience strongly preferred in one or more of the following: HMO, Health plan, Medicare, Utilization Management, Case Management

Facility Location


Job Benefits

NursesRx, an AMN Healthcare company, is a leading travel nursing staffing agency that can help you achieve the career you've trained for, and the lifestyle you've always wanted. With thousands of positions nationwide, NursesRx lets registered nurses (RN) choose from the very best assignments with top-ranked hospitals and facilities throughout the United States. AMN Healthcare is an EEO/AA/Disability/Protected Veteran Employer.  We encourage minority and female applicants to apply.

About the Company

NursesRx, an AMN Healthcare company, is a leading travel nursing staffing agency that can help you achieve the career you've trained for, and the lifestyle you've always wanted. With thousands of positions nationwide, NursesRx lets registered nurses (RN) choose from the very best assignments with top-ranked hospitals and facilities throughout the United States. AMN Healthcare is an EEO/AA/Disability/Protected Veteran Employer.  We encourage minority and female applicants to apply.

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