Utilization/Appeals Review Nurse

  • AllMed
  • Remote
  • Apr 09, 2021
Registered Nurse

Job Description

Are you seeking career growth that allows you to advocate for healthcare needs in a new and different way? Are you looking for a position that doesn’t require shift work, nights or regularly scheduled weekends/holidays? Does the potential for working from home intrigue you? 

If you answered yes to any of these questions, this Utilization/Appeals Review position may be the change you’ve been seeking.   

AllMed provides clinical decision making and utilization management solutions to leading payer and provider organizations. We work closely with clients toward a shared vision of healthcare that delivers the highest quality, values patient experience, and ensures both appropriate care and utilization of health-related services. AllMed is mission driven to improve the quality and integrity of healthcare and is a recognized leader in this dynamic market.   

We are currently seeking experienced Utilization/Prior Authorization/Appeals Review Nurses to join our clinical operations team, working onsite in our beautiful office in downtown Portland, Oregon or remote from home. 

Position Description 

In this role, you will work closely with our medical directors and national peer physician specialist panel to provide written medical chart reviews and determinations, which power prior authorizations and appeals for medical treatments and procedures in nearly all specialties and sub-specialties of medicine. The Utilization/Appeals Review Nurse role includes: 

  • Performing prior authorization reviews/approvals against clinical criteria 

  • Reviewing medical records and preparing case summaries for physician review of prior authorizations and appeal determinations that align with health plan policies and clinical review criteria 

  • Ensuring the accuracy of determinations by validating information in the medical record against health plan policies and clinical review criteria 

  • Ensuring the quality of final written reviews by close attention to grammar, punctuation, spelling, formatting, and accuracy 

  • Meeting quality and productivity standards  

  • Working to continuously improve the quality and efficiency of our operations through individual and team projects, participation in continuous improvement events and ongoing learning 

Experience, Knowledge, Skills, and Abilities 

  • Current unrestricted Registered Nurse (RN) license 

  • Minimum one year clinical nursing experience; med-surg or critical care experience preferred 

  • Ability to type minimum 35 words per minute 

  • Excellent writing and documentation skills and customer service 

  • Computer literacy with demonstrated proficiency in Microsoft Office, email, database and contact management software, and browser-based workflow applications 

  • Exhibit a high degree of professionalism in written and verbal communications 

  • Attention to detail; critical eye to catch mistakes and errors 

  • Experience in a fast-paced, production-oriented setting  

  • Demonstrated experience in utilization management, case review and/or medical necessity review/appeals in a payer, provider or independent review organization setting  

  • Bachelor of Nursing or degree in equivalent field of study  

BENEFITS 

AllMed offers generous compensation and our competitive benefits program includes comprehensive medical, dental, and vision care, matching 401K, paid time off, disability coverage, and other benefits that promote employee wellness. 

AllMed provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, AllMed complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities.