Utilization Review Nurse Auditor (33034)

ExamWorks is looking for a Utilization Review Nurse Auditor to join their team!

The Utilization Review Nurse Auditor is responsible for performing quality utilization review services and approving care that is medically necessary and appropriate according to evidenced based guidelines and criteria. This position ensures reports are completed with the highest quality and integrity and that all work is in full compliance with client contractual agreements, regulatory agency standards and/or federal and state mandates.

*Please note that this jobs requires you to obtain your CPC certification within 6 months of hire

The position is 100% remote with a schedule of Monday through Friday: 8:00am-5:00pm EST

• Perform quality utilization review through the use of acquired knowledge and application of evidenced based guidelines for peer review reports, correspondences, addendums and/or supplemental reviews.
• Work directly with providers to identify level, intensity and duration of care.
• Document findings, continue to evaluate medical necessity for frequency, intensity and length of required care.
• Assure that the consistency and quality of reviews meets or exceeds industry standards.
• Work to ensure quality reviews are completed within the required client, federal and state or URAC mandated turnaround times.
• Maintain and apply knowledge of URAC and other state and federal regulatory requirements.
• Maintain accurate record of Utilization Reviews within the appropriate database.
• Direct Customer Service Representatives to ensure timely delivery of determination letters.
• Assist in resolution of client complaints and/or quality assurance issues as needed.
• Ensure all quality assurance standards and federal ERISA, URAC, and/or other state guidelines are adhered to at all times.
• Provide insight and direction to management on any compliance concerns regarding products, company policies and procedures and/or client specifications.
• Participate in company meetings, training activities and continuing education requirements.
• Perform all other duties as assigned.