Introduction TurningPoint Healthcare Solutions is a rapidly growing and innovative healthcare company that supports several large national health plans to improve the quality and affordability of healthcare patients receive. We are looking for motivated individuals who want to be part of our mission and join our team!
This is a fully remote position with multiple shifts available.
Job Summary The Utilization Review Nurse will utilize their critical thinking skills, clinical expertise, and judgment along with established medical criteria to perform first-level clinical review for select procedures that require medical necessity authorization. The ideal candidate will have an extreme attention to detail, an ability to flourish in a fast-paced environment, and advanced grammar, punctuation, and computer skills.
Responsibilities Perform initial clinical reviews and provide documented recommendations based on the use of appropriate clinical guidelines.
Review the initial evaluation and clinical documentation against clinical standards, applicable state regulations, and relevant treatment guidelines.
Assist clinical staff in quality improvement projects to provide instructive feedback to clients and providers within scope of practice.
Resolve patient care issues by working one-on-one with community providers and staff to resolve issues in the determination process.
Provide information by responding to queries of physicians and their practice staff, sorting and distributing messages and documents, and preparing information for determinations.
Improve quality results by studying, evaluating procedures and processes and recommending changes, if needed.
Serve and protect the company by adhering to accreditation standards, professional standards, company policies and procedures, federal, state, and local requirements, and professional and licensing standards.
Qualifications Licensed Practical Nurse.
Comprehensive knowledge of general nursing theory and practices.
Excellent customer service skills and phone etiquette.
Proficient computer skills, including typing and an ability to maneuver through various programs.
Previous Utilization Management experience preferred but not required.
Knowledge of musculoskeletal surgical procedures, cardiac procedures, pain management, and/or wound care is a plus.
Ability to multi-task and manage tasks to completion on a timely basis and in an organized fashion.
Ability to work collaboratively as part of a team.
Job Details Seniority level: Entry level.
Employment type: Full-time.
Job function: Health Care Provider.
Industry: Hospitals and Health Care.
TurningPoint Healthcare Solutions provided pay range: $52,000.00/yr - $58,000.00/yr.