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Adecco Healthcare & Life Sciences is hiring **Utilization Management Nurses** ! This role is work from home and remote but we are requiring Nurses to live in Texas. Please review the details below and apply with an updated resume.

**Position Type** : Temp to Hire

**Schedule** : Monday – Friday, 9am – 6pm CST, rotating Saturday once a month

**Pay** : $40.00 - $43.25 per hour based on experience

**Responsibilities of the Utilization Management Nurse** :

• Responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines.

• The UM Nurse determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.

• Generally work is self-directed and not prescribed.

• The Utilization Management Nurse works under the direct supervision of an RN or MD.

• Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines.

• Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria.

• Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.

• Answers Utilization Management directed telephone calls; managing them in a professional and competent manner

• Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turn around times.

• Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information. Sends appropriate system-generated letters to provider and member.

• May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses.

• Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department.

**Qualifications** **of the Utilization Management Nurse** :

• Knowledge of Home Health processes.

• Registered Nurse with a current license to practice in the state of employment

• Current compact RN Licensure to practice in the applicable states

• 2+ years of experience in managed care, Utilization Review, Case Management or 5+ years nursing experience

• Relevant experience in UM process activities such as prior authorization or medical claims review

• Resides in Texas

Why work for Adecco?

• Weekly Pay

• 401(k) Plan

• Skills Training

• Excellent medical, dental, and vision benefits

**IMPORTANT:** This **Utilization Management Nurse** job is being recruited for by Adecco’s Healthcare & Life Sciences division, not your local Adecco Branch Office.

For opportunities available at Adecco Healthcare & Life Sciences go to https://www.adecco.com/en-us/employers/industries/healthcare-life-sciences

**Pay Details:** $40.00 to $43.25 per hour

Benefit offerings available for our associates include medical, dental, vision, life insurance, short-term disability, additional voluntary benefits, EAP program, commuter benefits and a 401K plan. Our benefit offerings provide employees the flexibility to choose the type of coverage that meets their individual needs. In addition, our associates may be eligible for paid leave including Paid Sick Leave or any other paid leave required by Federal, State, or local law, as well as Holiday pay where applicable.

Equal Opportunity Employer/Veterans/Disabled

To read our Candidate Privacy Information Statement, which explains how we will use your information, please navigate to https://www.adecco.com/en-us/candidate-privacy

The Company will consider qualified applicants with arrest and conviction records in accordance with federal, state, and local laws and/or security clearance requirements, including, as applicable:

+ The California Fair Chance Act

+ Los Angeles City Fair Chance Ordinance

+ Los Angeles County Fair Chance Ordinance for Employers

+ San Francisco Fair Chance Ordinance