Overview Utilization Review Nurse – Integrated Resources, Inc (IRI). This role supports the prior authorization team. Pay Rate: $42/hr on W2 Location: Seattle, WA Schedule: Likely 8:00 AM – 5:00 PM CST or 9:00 AM – 6:00 PM CST/PST/EST; may require weekends and holidays. Responsibilities Work with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate integrated care across the continuum, including behavioral health and long-term care, for members with high-need potential. Assess services for optimum outcomes, cost-effectiveness and compliance with state and federal regulations and guidelines. Analyze clinical service requests from members or providers using evidence-based clinical guidelines. Identify appropriate benefits and eligibility for requested treatments and/or procedures. Conduct prior authorization reviews to determine financial responsibility for the organization and its members. Process requests within required timelines. Refer appropriate prior authorization requests to Medical Directors. Request additional information from members or providers in a consistent and efficient manner. Make appropriate referrals to other clinical programs. Collaborate with multidisciplinary teams to promote the Client Care Model. Adhere to UM policies and procedures. Qualifications Completion of an accredited Registered Nurse (RN) program and active, unrestricted RN license in good standing. Active RN license in WA, FL, IL, NM, TX, OH (or other applicable state) with ability to practice. 1-3 years of hospital or medical clinic experience. 1+ year Prior Authorization or Utilization Management experience; 2+ years Prior Auth, MCO and/or UM experience preferred. Proficiency in evaluating evidence-based guidelines and determining benefits/eligibility for treatments. Additional details May need to work weekends/holidays and may require work across time zones (CST/PST/EST). #J-18808-Ljbffr Integrated Resources, Inc ( IRI )
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