The job posting you’ve shared outlines the role of a Utilization Management Nurse Reviewer at Dane Street, detailing both the responsibilities and qualifications required for the position. This is a clinical role focused on reviewing medical records, treatment plans, and patient information to determine the appropriateness and necessity of medical services, with a focus on controlling costs while maintaining quality care.

Here’s a summary of the key points:

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Role and Responsibilities

Conduct assessments of medical services to ensure they meet medical necessity criteria, such as CMS, Milliman Care Guidelines, or InterQual.
Examine patient records to verify the quality and necessity of services.
Provide clinical expertise and guidance to non-clinical staff members.
Manage essential clinical information on medical management platforms.
Stay updated on regulatory requirements and ensure adherence to state standards for utilization review.
Collaborate with physicians, management teams, and the Medical Director to ensure high-quality patient care.
Oversee quality issue reports and work on continuous improvement of the review process.

Requirements

Licensing: A current, unrestricted LVN or RN license from an accredited program is required.
Experience: At least 2 years of clinical nursing experience and 1 year of Utilization Management experience.
Proficiency in Microsoft tools (Word, Excel, PowerPoint, Outlook).
Strong written and spoken communication skills, organizational abilities, and attention to detail.
Work Environment: Ability to work from home with an uninterrupted internet connection, maintaining a comfortable home office setup.

Additional Details

PRN/On-Call Position: Flexible staffing to support the team during peak times, requiring availability for weekends and holidays.
Education/Training: Ongoing professional development and skills acquisition to adapt to evolving tools and systems.
Benefits: Comprehensive health coverage, paid time off, 401k with company match, life insurance, disability coverage, and more.

Compensation

Starting compensation will be based on experience, education, and skills, with opportunities for bonuses and other incentives.

About Dane Street

Dane Street is a high-performance company, processing over 200,000 insurance claims annually for major national and regional health carriers and other industry partners. The company is committed to diversity, inclusion, and competitive compensation.

If you’re interested, applying for the role could provide a valuable opportunity to leverage your clinical expertise in an impactful, flexible position with competitive benefits.

PRN Utilization Review Nurse Reviewer – LPN -id-5249