Utilization Management Nurse

Job Description

Job Description

The Utilization Management nurses facilitate, coordinate and approve of medically necessary reviews that meet established criteria. Assures timely and accurate determination and notification of reviews and reconsiderations based on the review determination status. Generates approval, modifications and denials communications, to include member and provider notification of review determination.

Job Duties and Responsibilities:

Utilization Management:

• Performs prospective, concurrent, post-service and retrospective claims medical review processes. Utilizing considerable clinical judgement, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies cases needing Physician Advisor (PA) review or input. Presents cases to PA for potential review or determinations when needed.

• Performs telephonic admission and concurrent review, and collaborates with on-site facility staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan, if contracted by client.

• Maintain accurate records in the designated medical management system

• Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.

• As contracted by the client, research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network.

• Potential quality of care/potential fraud issues are identified and documented per client policy. High risk/high-cost cases and reports are maintained and referred to the Physician Advisor/UM Director.

• Provide updates to Manager of Utilization Management

• Perform other duties as assigned.

Skills and Qualifications:

• Education Preferred: Bachelor's degree in nursing

• Licensure as a Registered Nurse (RN) required

• Minimum 3 years of prior experience in Health Insurance Company Utilization Management

• Strong understanding of using InterQual Criteria

• Strong knowledge of word processing and working with care management platforms or spreadsheet computer programs

• Utilization Management certification preferred for UM nurses

• Ability to stay organized and interact well with others

Job Types: Full-time, Contract

Schedule:

• 8-hour shift

• Monday to Friday

Work Location: Remote