Utilization Review Nurse

Company Overview

HealthAxis is a prominent provider of core administrative processing system (CAPS) technology, business process as a service (BPaaS), and business process outsourcing (BPO) capabilities to healthcare payers, risk-bearing providers, and third-party administrators. We are transforming the way healthcare is administered by providing innovative technology and services that uniquely solve critical healthcare payer challenges negatively impacting member and provider experiences.

We live and work with purpose, care about others, act with integrity, communicate with transparency, and don’t take ourselves too seriously.

We're not just about business – we're about people. Our commitment to a people-first approach shapes everything we do, from collaborating as a team to serving our valued clients. We believe that creating a vibrant and human-centric environment can inspire engagement, empower our team members, and ignite a sense of purpose in all that we accomplish.

Purpose And Scope

The Utilization Review Nurse is responsible for the medical necessity review of outpatient services that require prior authorization, and / or management of concurrent inpatient admissions. The medical necessity review process includes assessment and interpretation of plan specific benefits, medical criteria, and clinical documentation.

Principal Responsibilities And Duties

• Performs prospective, concurrent, and retrospective inpatient and / or outpatient utilization reviews (UR) using evidence-based guidelines, policies and nationally recognized clinical criteria, and internal policies and procedures.
• Evaluates severity of illness and intensity of service of member’s needs at time of inpatient admission utilizing approved criteria.
• Triage and prioritize cases and other assigned duties to meet CMS turnaround time standards.
• Prepare and escalate cases to MDs for review when appropriate.
• Demonstrates effective communication methods and skills, using lines of authority appropriately.
• Establishes a relationship with providers to determine / provide needed services to member.
• Maintains accurate record of UR activities.
• Adheres to quality standards and confidentiality policies and procedures.
• Ensures compliance with all state and federal regulations and guidelines in day-to-day activities.
• Adapts to changes in policies, procedures, new techniques, and additional responsibilities.

Customer Service

Education, Experience And Required Skills