About the Company
Kaiser Permanente is one of the largest not-for-profit healthcare plans in the United States, serving millions of members. We are dedicated to providing high-quality, affordable healthcare services and improving the health of our communities. Our integrated healthcare model emphasizes preventive care and patient-centered services. Join a team committed to innovation and excellence in healthcare.
Job Description
We are seeking a highly motivated and experienced Utilization Review Nurse with an administrative focus to join our remote team. This role is crucial for ensuring the appropriate allocation of healthcare resources by reviewing medical necessity, appropriateness, and efficiency of healthcare services. The ideal candidate will leverage their clinical expertise to perform comprehensive reviews, collaborate with providers, and ensure compliance with regulatory standards and internal policies. This position is entirely remote, offering flexibility and the opportunity to contribute to our mission from anywhere.
Key Responsibilities
- Perform concurrent and retrospective reviews of medical records to determine the medical necessity and appropriateness of services.
- Apply evidence-based criteria (e.g., InterQual, Milliman Care Guidelines) to evaluate cases and make informed decisions.
- Communicate professionally and effectively with physicians, healthcare providers, and interdisciplinary teams regarding review findings.
- Document all review activities accurately and timely in the electronic health record system.
- Identify potential over or under-utilization of healthcare services and escalate complex cases as necessary.
- Participate in interdepartmental meetings and contribute to process improvement initiatives.
- Maintain current knowledge of regulatory requirements, payer guidelines, and industry standards.
- Collaborate with care management teams to facilitate smooth transitions of care and appropriate resource utilization.
- Assist in the development and revision of utilization review policies and procedures.
Required Skills
- Active Registered Nurse (RN) license in Maryland (or compact state eligibility)
- Minimum of 3 years of clinical nursing experience
- Minimum of 2 years of experience in Utilization Review, Case Management, or Managed Care
- Proficiency in applying InterQual or Milliman Care Guidelines
- Strong understanding of healthcare regulations (e.g., Medicare, Medicaid, commercial plans)
- Excellent written and verbal communication skills
- Proficient computer skills, including electronic health records (EHR) and Microsoft Office Suite
- Demonstrated ability to work independently and manage time effectively in a remote environment
Preferred Qualifications
- Bachelor of Science in Nursing (BSN)
- Certification in Case Management (CCM) or other relevant certifications
- Experience with Epic EHR system
- Knowledge of Quality Improvement methodologies
- Previous experience in a remote nursing role
Perks & Benefits
- Comprehensive health, dental, and vision insurance
- 401(k) with company match
- Generous paid time off and holidays
- Remote work flexibility
- Professional development and continuing education opportunities
- Employee wellness programs
- Life insurance and disability benefits
- Opportunities for career advancement within a large healthcare system
How to Apply
If you are interested in this position, please click the "Apply Now" button below. To ensure your application is properly considered, please prepare the following:
- An up-to-date Resume or CV
- A brief cover letter summarizing your experience and motivation
Applications are reviewed on a rolling basis. Only shortlisted candidates will be contacted for an interview.
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