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DME Utilization Management Reviewer - Nursing

Expired Job

Evicore Franklin , TN 37064

Posted 2 months ago


The Registered Nurse or Licensed Practical Nurse will be responsible for performing Prior Authorization Reviews for our Customers of Durable Medical Equipment (DME). The Registered Nurse or Licensed Practical Nurse will review Clinical Documentation provided by Physicians/ Providers/ Suppliers to established company protocols and clinical guidelines and then Documenting decisions utilizing criteria that is based on established Evidence Based Practice Guidelines. The Registered Nurse or Licensed Practical Nurse will house the ability to provide excellent customer service by handling confidential and sensitive information with discretion during collaboration and communication with external and internal contacts ensuring the development of strong relationships with these stakeholders while clearly representing business needs as well as business determinations. The Registered Nurse or Licensed Practical Nurse will possess a clear, straightforward and reasonably concise style in writing documents, paying attention to detail including spelling and grammar while effectively transferring thoughts, information and ideas in a timely and concise manner.

Minimum Experience Required

Current unrestricted Registered Nurse or Licensed Practical Nurse licensure

Minimum 2- 3 years clinical experience.Experience in Medical Surgical Nursing, Home Health Nursing, Rehabilitation, Case Management, ICD 9 or ICD 10 experience desired however not all are required. Knowledge of Center of Medicare Services (CMS) Medicare/Medicaid Regulations and Interqual/Milliman preferred.DME Utilization Review experience desired

Required Skills

Position is located in onsite business office, and/or remote Position is full-time during core business hours with the ability to work any shift between 7am and 6pm CST, plus mandatory on call responsibility after business hours equivalent to approximately two weekends per year. Ability to sit at a desk 75% of the time and utilize the computer, telephone, and other office equipment, throughout the entire work day.Dependable and reliable work schedule is essential

Nursing Knowledge Professional: Maintains a vast knowledge base of professional nursing theory, techniques, practices and procedures and a considerable knowledge of medical terminology, disease process, and body systems. Understands current clinical diagnostic procedures and treatments and skills in applying these to individual cases. Remains current on general knowledge of state and federal rules and regulations governing financial reimbursement and the impact they have when applied across the nursing continuum.Time-management: Ability to effectively manage one's time and resources to ensure that work is completed efficiently Excellent organizational skills

Communication: Ability to provide clear verbal and written information via in-person, email, and phone to customers, co-workers, and leadership

Critical-Thinking/Decision-making: Ability to choose a course of action or developing appropriate solutions by identifying and understanding issues, problems, and opportunities

Autonomy: Ability to work independently with little to no supervision

Proficient in computer literacy skills with ability to use and troubleshoot Microsoft Word, Excel, Outlook, and PowerPoint required

Experience using videoconferencing systems such as WebEx

Our Company and What We Offer


Core healthcare is committed to making a positive impact on healthcare, and also making a positive impact on our employees. evi

Core offers a variety of perks and benefits including, but not limited to:

  • Flexible scheduling and work/life balance with remote and work from home opportunities

  • 3 weeks of PTO(starting) per year plus paid holidays

  • Education assistance, tuition reimbursement and professional certifications

  • Health, dental, vision, and life benefits with employer funded HSA

  • Comprehensive employee discount program, onsite fitness facilities, and smart casual dress code

  • Paid Volunteer Community Service Days

  • Ample opportunities for growth, advancement, and promotion

  • 401k retirement plan with company match of 50% employee contributions up to 6%

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DME Utilization Management Reviewer - Nursing

Expired Job