Utilization Review RN

Transforming the future of healthcare isn't something we take lightly. It takes teams of the best and the brightest, working together to make an impact. As one of the largest healthcare technology companies in the U.S., we are a catalyst to accelerate the journey toward improved lives and healthier communities.Here at Change Healthcare, we're using our influence to drive positive changes across the industry, and we want motivated and passionate people like you to help us continue to bring new and innovative ideas to life.If you're ready to embrace your passion and do what you love with a company that's committed to supporting your future, then you belong at Change Healthcare. Pursue purpose. Champion innovation. Earn trust. Be agile. Include all. Empower Your Future. Make a Difference. 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 is a remote position and must be able to work 10 a.m. - 6 p.m. CT zone What will be my duties and responsibilities in this job? Managing utilization and, if necessary, discussing utilization of service and standards of patient management 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 Participate in case review and/or team meetings with managerial team and Medical Director What are the requirements needed for this position? RN required; Preferred: Bachelor's Degree in Nursing Minimum of 3-5 years of clinical experience Minimum one year of care management, utilization management experience, clinical documentation or clinical auditing experience Arizona or Multi State Nursing License (compact license) required Excellent computer literacy and beginning to moderate skills level with Microsoft Word and Excel What other skills/experience would be helpful to have? Knowledge of precertification and/or medical review processes in a health care payor or third partyenvironment. Strong critical thinking and analytical Strong verbal and written communication skills Medical terminology Strong interpersonal skills Able to work independently Knowledge of medical appropriateness criteria such as InterQual, Milliman Care Guidelines Knowledge of CPT, ICD-10, and/or HCPC codes or coding experience Knowledge of URAC or NCQA standards What are the working conditions and physical requirements of this job? General office demands Join our team today where we are creating a better coordinated, increasingly collaborative, and more efficient healthcare system! 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 https://www.eeoc.gov/employers/eeo-law-poster and the supplemental information at https://www.dol.gov/ofccp/regs/compliance/posters/pdf/OFCCP_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 applyaccommodations@changehealthcare.comwith "Applicant requesting reasonable accommodation" as the subject. Resumes or CVs submitted to this email box will not be accepted. Click here https://www.dol.gov/ofccp/pdf/pay-transp_%20English_formattedESQA508c.pdfto view our pay transparency nondiscrimination policy. 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. Employment at Change Healthcare is based upon your individual merit and qualifications. We don't discriminate on the basis of race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, marital status, protected veteran status or disability, genetic characteristic, or any other characteristic protected by applicable federal, state or local law. We will also make all reasonable accommodations to meet our obligations under the Americans with Disabilities Act (ADA) and state disability laws. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability.