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Utilization Review Nurse in Folsom, CA at PrideStaff

Date Posted: 8/8/2018

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Job Description

Utilization Review Nurse – Folsom, CA

Our client, a well-known Third Part Administrator of group health plans, is looking for an experience Utilization Review Nurse to join their growing team of health insurance professionals. The Utilization Review Nurse is responsible for various tasks with respect to medical care authorization, delivery and management of care. The Utilization Review Nurse will be part of a management team and follows best practices and principles to ensure the highest quality and cost-effective care.


  • Work in-office daily with consistent attendance
  • Authorize medical services by using medical policy guidelines of the department to process sensitive and confidential information; refer the request to an RN Medical Case Manager or a Physician Reviewer as appropriate.    
  • Serve as a liaison between the case manager and medical management coordinators regarding medical review issues
  • Conduct pre-certification, concurrent, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the member’s eligibility, benefits and contract
  • Develop relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
  • Communication with hospitals, physicians, and subscribers regarding certification of hospital admissions, outpatient services and post procedure follow up
  • Maintains communication between insured, medical provider, and insurance company.
  • Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. Refers treatment plans/plan of care to case manager, peer clinical reviewers in accordance with established criteria/guidelines and issue medical necessity non-certifications if needed.
  • Examine DRG pre-certification, certification of admissions, and continued stay
  • Maintain medical standards for all clients based on their individual health benefit plans
  • Maintains compliancy with regulation changes affecting medical management
  • May assess and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process
  • Review all medical reports to identify treatment requests within 24 hours of receipt    
  • Review medical information from various out of state facilities as necessary
  • Review medical reports thoroughly to ensure treatment is consistent with the diagnosis provided and follow up with continued patient care
  • Perform other duties and responsibilities as assigned by the Management.


  • 2+ years of clinical experience with at least 1 year of case management or utilization review experience; or equivalent and any combination of education, training, and/or experience, which demonstrates ability to perform the duties described
  • Knowledge of all state and federal mandated laws and regulations
  • Understanding and ability to utilize evidence based medical guidelines
  • Ability to effectively evaluate patient care
  • Strong knowledge of medical terminology
  • Ability to work independently and within a team environment, including ability to coordinate a team for effective results
  • Strong verbal and written communication skills and ability to present information effectively, tailor presentations to a wide variety of audiences (including executive management), present complex concepts and recommendations clearly for management decision-making purposes.
  • Strong customer service skills
  • Strong organizational skills which support timely and well documented action to manage concurrent deadlines and multiple priorities
  • Ability to continue adjusting in a dynamic and fast-paced environment
  • Intermediate working knowledge of Microsoft Office, Excel, windows based products, and other types of standard office equipment. Minimum 45wpm and 10 key by touch preferred.
  • Must be able to work within core hours of operation 7am to 5pm Monday through Friday

Why Insurance Relief™?
As a businessperson in the insurance industry, it is an advantage to partner with a staffing expert and ally who understands your unique skills and needs. With vast experience in the insurance arena, Insurance Relief™ works with brokers, carriers and third party administrators to locate and place the best people for positions ranging from entry level to senior management. We invest the time to truly understand what you want to accomplish, and then do our best to find meaningful opportunities.

Insurance Relief™ provides ample opportunities for you to put your skills to work so if this position is not quite the fit for you please give us a call to hear about all of the other opportunities we have available.

Contact us today! All Inquiries are kept confidential., 888-292-4440