Clinical Utilization Review Nurse

3 weeks ago


Dubai, Dubai, United Arab Emirates ClickJobs Full time
Job Title: Clinical Utilization Review Nurse

At ClickJobs, we are seeking a highly skilled Clinical Utilization Review Nurse to join our team. As a key member of our Utilization Review team, you will play a critical role in ensuring that our members receive the highest quality care while minimizing unnecessary costs.

Key Responsibilities:
  • Coordinate and review medical records to assess whether the criteria for admission and continuation of treatment is being met.
  • Participate in Case Management and Treatment Team meetings to ensure seamless communication and coordination of care.
  • Provide education to all departments on utilization review best practices and guidelines.
  • Review patient charts to identify opportunities for cost savings and quality improvement.
  • Communicate with fiscal intermediaries, patients, and families to ensure timely and accurate referral determinations.
  • Identify referrals for review by the medical director and ensure proper coding and documentation.
  • Work closely with the supervisor/lead to address issues and delays that can impact compliance.
  • Meet or exceed production and quality metrics.
Requirements:
  • CA LVN license required; CA RN license preferred.
  • Bachelor's or Master's degree in Social Work, behavioral or mental health, nursing, or other related health field preferred.
  • 3 to 5 years of acute care experience preferred.
  • 2 years of managed care experience in UM/CM Department preferred.
Preferred Skills and Abilities:
  • Knowledge of CMS, State Regulations, URAC, and NCQA guidelines.
  • ICD-9 and CPT coding experience a plus.
  • Experience working with Microsoft Word, Outlook, Excel, and health plan medical management documentation systems a plus.
  • Experience with EZ-CAP preferred.
  • Medical Terminology preferred.


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