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

Calling all adventure-seeking Registered Nurses (RNs) with expertise in Utilization Review! Are you ready to embark on an 8-week travel healthcare assignment in sunny Torrance, California? This is your opportunity to dive into a new environment, expand your skill set, and make a difference while enjoying the beautiful West Coast vibes. As a dedicated RN specializing in Utilization Review, you will play a crucial role in assessing the efficiency and quality of healthcare services provided, ensuring that patients receive the appropriate care they need. Your attention to detail and analytical skills will be instrumental in optimizing patient outcomes and healthcare resources during this assignment in Torrance, California. At TLC Nursing, we understand the importance of supporting our healthcare professionals. That's why we offer 24/7 recruiter assistance, personalized career guidance, and assistance with housing and licensing. Join a company founded by nurses, where your well-being and success are our top priorities. In addition to the rewarding work you'll be doing, here are some of the benefits you can enjoy: - Best in the Industry Pay Packages - $25,000 Life Insurance Policy – Effective from Day One - Medical, Dental, and Vision Insurance – available the 1st of the month after hire - Paid Time Off – Accrued Day 1, eligible after 1 year of employment (unless required earlier by state law) - 401(k) – Available after 1 year of employment; fully vested after 5 years - Aflac – Available for employee purchase - Referral Program – Payouts for referring other healthcare professionals - EAP – Free, confidential services for employees and their households via Invest EAP If you're ready to take your Utilization Review skills to the next level in Torrance, California, and experience the TLC difference, apply now! Your next adventure awaits.

Apply now