Job Overview

TLC Nursing Associates, Inc. is seeking an experienced Registered Nurse (RN) – Utilization Review to assess the medical necessity, efficiency, and appropriateness of healthcare services. This role involves reviewing patient care plans, ensuring compliance with insurance guidelines, and collaborating with healthcare providers to optimize resource utilization.

Responsibilities

Conduct comprehensive reviews of patient records to determine medical necessity and adherence to clinical guidelines
Ensure compliance with Medicare, Medicaid, and private insurance policies
Communicate with physicians, case managers, and insurance representatives to validate treatment plans
Provide detailed documentation and justifications for medical necessity appeals and authorizations
Analyze utilization trends and recommend improvements for cost-effective patient care
Assist in denials management and appeals processing
Stay up to date with healthcare regulations and payer requirements
Participate in quality improvement initiatives to enhance resource utilization and patient outcomes

Qualifications

Active Registered Nurse (RN) license in applicable state(s)
Minimum 2 years of experience in utilization review, case management, or healthcare administration
Certification in Basic Life Support (BLS) required
Certified in Utilization Review (UR) or Case Management (CCM, ACM) preferred
Strong understanding of insurance policies, reimbursement methods, and regulatory requirements
Excellent critical thinking, documentation, and communication skills
Proficiency with electronic medical records (EMR) and utilization review software

Benefits

Competitive salary and shift differentials
Housing and meal allowances (if applicable)
Medical, dental, and vision insurance
401(k) retirement plan options
Continuing education and certification reimbursement
Career advancement opportunities

Job Description

Are you a passionate Registered Nurse (RN) with expertise in Utilization Review seeking a thrilling adventure in Arcata, California? Look no further! In this exciting travel healthcare assignment, you will dive into a unique opportunity to make a difference while exploring the charming coastal city of Arcata. As a travel nurse specializing in Utilization Review, you will play a crucial role in evaluating healthcare services to ensure optimal patient outcomes and cost-effectiveness. Your responsibilities will include conducting comprehensive reviews of patient medical records, collaborating with healthcare providers to determine the necessity of treatments, and recommending appropriate care plans. Your keen eye for detail and analytical skills will be instrumental in identifying opportunities to enhance the quality and efficiency of healthcare delivery. At TLC Nursing, we understand the importance of supporting our healthcare professionals every step of the way. As a nurse-founded agency, we provide 24/7 recruiter support, personalized career guidance, and assistance with housing and licensing to ensure your assignment in Arcata is seamless and rewarding. Join us for this 13-week travel healthcare assignment and enjoy Best in the Industry Pay Packages with a weekly pay of $1747.0. Additionally, you will receive a $25,000 Life Insurance Policy effective from day one, medical, dental, and vision insurance starting the 1st of the month after hire, and paid time off accrued from day 1, eligible after 1 year of employment. Take advantage of our 401(k) plan available after 1 year of employment and fully vested after 5 years, Aflac options for employee purchase, a Referral Program with payouts for referring other healthcare professionals, and access to our Employee Assistance Program (EAP) for free, confidential services for you and your household via Invest EAP. Don't miss this opportunity to embark on a fulfilling journey as a travel nurse in Arcata, California. Apply now and let your nursing expertise shine in a picturesque setting while making a positive impact on patient care.

Apply now