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REGENCE BLUECROSS BLUESHIELD OF UTAH Regence Utilization Review Nurse in SALT LAKE CITY, Utah

Regence Utilization Review Nurse Portland, OR; Lewiston, ID; Burlington, WA; Boise, ID; Tacoma, WA; Salt Lake City, UT; Salem, OR; Telecommute within OR, UT, ID or WA. Candidates residing outside of these 4 states will not be considered.Are you a Registered Nurse that is passionate about making a difference? In this position, you would provide utilization management (such as prospective concurrent and retrospective review) to best meet the member's specific healthcare needs and to promote quality and cost-effective outcomes and appropriate payment for services.Responsibilities* Prospective: Utilization management conducted prior to a patient's admission, stay, or other service or course of treatment (including outpatient procedures and services). Sometimes called "precertification review" or "prior authorization," prospective review can include prospective prescription drug utilization review.* Concurrent: Utilization management conducted during a patient's hospital stay or course of treatment (including outpatient procedures and services). Sometimes called "continued stay review".* Retrospective: Review conducted after services (including outpatient procedures and services) have been provided to the patient.* Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license.* Consults with physician advisors to ensure clinically appropriate determinations.* May facilitate transitions of care through collaboration with the member, the facilities interdisciplinary team and Regence's Case Management to achieve optimal recovery for the member.* Serves as a resource to internal and external customers.* Collaborates with other departments to resolve claims, quality of care, member or provider issues.* Identifies problems or needed changes, recommends resolution, and participates in quality improvement efforts.* Responds in writing, by phone, or in person to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues.* Provides consistent and accurate documentation.* Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established timelines.Competencies and Knowledge:* Knowledge of health insurance industry trends, technology and contractual arrangements.* General computer skills (including use of Microsoft Office, Outlook, internet search).* Familiarity with health care documentation systems. -* Strong verbal, written and interpersonal communication and customer service skills.* Ability to interpret policies and procedures and communicate complex topics effectively.* Strong organizational and time management skills with the ability to manage workload independently.* Ability to think critically and make decisions within individual role and responsibility.Normally to be proficient in the competencies listed above:* Utilization Management Nurse would have a-an Associate or Bachelor's Degree in Nursing or related field and 3 years of case management, utilization management, disease management, auditing or retrospective review experience or equivalent combination of education and experience.Required Licenses, Certifications, Registration, Etc.* Must have Registered nurse (RN) license (must have a current unrestricted RN license for medical care management) and at least 3 years (or full time equivalent) of direct clinical care.Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. We are an equal opportunity employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without reg

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