Post Review Nurse - Utilization Management
We are seeking a dedicated Post Review Nurse to join our Utilization Management team. In this role, you will perform timely utilization management reviews and claims assessments using InterQual criteria and medical policy. You will work collaboratively with internal care management teams to ensure member needs are met, while maintaining high standards of quality and compliance.
Responsibilities:
- Conduct utilization management reviews and claims assessments using InterQual criteria.
- Review medical records for suspended claims and provider inquiries to determine medical necessity.
- Collaborate with internal care management teams to meet member needs.
- Meet production metrics, including a minimum of 40 reviews per day post-training, and maintain a quality assurance standard of 97%.
- Document reviews accurately and consistently in Frontier and other systems.
- Apply clinical criteria and benefit information to support medical review decisions.
- Ensure compliance with URAC, NCQA, HIPAA, and internal guidelines.
- Participate in cross-functional collaboration across divisions.
- Provide backup support to other UM teams, including precertification and continued stay reviews.
- Facilitate discharge planning and transition of care in collaboration with facilities and members.
- Perform other duties as assigned.
Essential Skills:
- Experience in utilization management and utilization review.
- Knowledge of medical policy and InterQual criteria.
- Understanding of HIPAA and NCQA standards.
- Proficiency in ICD9-CM, HCPC, and CPT coding systems.
- Active, unrestricted RN or LPN license in Iowa or South Dakota.
- 4+ years of clinical experience in acute or outpatient settings.
Additional Skills & Qualifications:
- Completion of an accredited RN or LPN program.
- Strong analytical and problem-solving skills.
- Excellent written and verbal communication skills.
- Attention to detail and ability to assess patient conditions via medical record review.
- Proficiency in electronic charting and Microsoft Office.
- Ability to work independently and make decisions under ambiguity.
- Strong organizational skills and ability to manage multiple priorities.
- Collaborative mindset and professionalism in stakeholder interactions.
- Quick learner with strong technical acumen.
Job Type & Location:
This is a Contract position based out of Des Moines, Iowa.
Pay and Benefits:
The pay range for this position is $35.00 - $40.00/hr. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:
- Medical, dental & vision
- Critical Illness, Accident, and Hospital
- 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available
- Life Insurance (Voluntary Life & AD&D for the employee and dependents)
- Short and long-term disability
- Health Spending Account (HSA)
- Transportation benefits
- Employee Assistance Program
- Time Off/Leave (PTO, Vacation or Sick Leave)
Workplace Type:
This is a fully remote position.
Application Deadline:
This position is anticipated to close on Sep 11, 2025.
About Actalent:
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law. If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email ...@actalentservices.com for other accommodation options.