Job Title: Post Review Nurse - Utilization Management

Job Description

We are seeking a diligent and detail-oriented Post Review Nurse to perform timely utilization management reviews and claims assessments. This role involves applying InterQual criteria and medical policy to evaluate medical records and determine medical necessity. You will collaborate with internal care management teams to ensure member needs are met and contribute to the overall efficiency and quality of our healthcare services.

Responsibilities

• Conduct utilization management reviews and claims assessments using InterQual criteria and medical policy.
• Review medical records for suspended claims and provider inquiries to determine medical necessity.
• Collaborate with internal care management teams to meet member needs.
• Meet production metrics, completing a minimum of 40 reviews per day post-training, and maintain quality assurance standards at 97%.
• Document reviews accurately and consistently in Frontier and internal systems.
• Apply clinical criteria and benefit information to support medical review decisions.
• Ensure compliance with URAC, NCQA, HIPAA, and internal guidelines.
• Participate in cross-functional collaboration across divisions.
• Provide backup support to other UM teams, including precertification and continued stay reviews.
• Facilitate discharge planning and transition of care in collaboration with facilities and members.
• Perform other duties as assigned.

Essential Skills

• Utilization management and utilization review experience.
• Acute care expertise.
• Knowledge of HIPAA, ICD, and CPT.
• Completion of an accredited RN or LPN program.
• Active, unrestricted RN or LPN license in Iowa or South Dakota.
• 4+ years of clinical experience in acute or outpatient settings.
• Familiarity with ICD9-CM, HCPC, and CPT coding systems.

Work Environment

This role is fully remote, allowing you the flexibility to work from a location where you are most productive. Candidates located in Iowa or South Dakota are preferred, and a high-speed internet connection is required. The position involves standard working hours from 8:00 AM to 5:00 PM CST. While the role is remote, there may be occasional requests to attend meetings or events in the office.