Registered Nurse (RN), Utilization Review MediGold Health Plan - Remote

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more. We know that exceptional patient care starts with taking care of our colleagues, so we invest in great people and all that we ask in return is that you come to work ready to make a difference and do the right thing.

The Utilization Review Nurse ensures that authorization requests and provider or member inquiries are handled appropriately within established timeframes, and established guidelines and protocols are utilized for clinical decision-making. In collaboration with providers and the Medical Director, the Utilization Review Nurse ensures medical appropriateness and effective utilization of health care resources.

Performs clinical review and provider/member notification in a timely manner. Partners and collaborates with provider partners on Utilization Review processes. Provides exceptional customer service to providers and members. Collaborates with management to promote improvements in work processes within department and organization. Responsible/accountable for professional development and maintaining licensure. Refers quality issues and poor utilization of services to the appropriate sources. Consults with Medical Directors as needed and as outlines in policies and procedures Coordinates activities with other medical management departments as needed, including making referrals to Case Management and Behavioral Health Attends and actively participates in staff meetings, participates in committees as requested. Provides orientation of other Utilization Review Nurses as requested. All other duties as assigned.