Regional UM Reviewer - This posting is open exclusively to current AL DOC incumbent employees.
NaphCare•Montgomery, AL
•Onsite
About The Position
This posting is open exclusively to current AL DOC incumbent employees. NaphCare Alabama Prisons LLC is hiring an experienced Regional UM Reviewer to join our team at the Regional Office in Alabama. The Utilization Management Reviewer/Manager performs technical and administrative work required to evaluate the necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities. The UM Nurse has an emphasis on the review, analysis, monitoring, and operation of the patient medical care plans.
Requirements
- A current and unrestricted RN license in the state of employment
- A minimum of 6 years’ experience in an acute care setting
- A minimum of 4 years’ experience in utilization review and/or case management
- Excellent communication and interpersonal skills
- Attention to detail
- Decision-making skills
Nice To Haves
- BSN
- Familiarity with Milliman Care Guidelines
Responsibilities
- Develop, implement, and administer the quality assurance and utilization review processes.
- Monitor and report on the quality of all facets of the medical care provided to patients.
- Perform utilization and concurrent review of patient cases.
- Conduct detailed clinical chart assessments.
- Gather clinical information to assess and expedite care needs.
- Determine need, if any, for intervention, and discussing with physicians.
- Reviews requests from providers regarding medical necessity of requested services for patients.
- Reviews and audits patients' medical records as indicated to determine medical necessity.
- Utilizes nationally recognized criteria to determine medical necessity of requested services.
- Refers provider requests to Medical Director or designee when medical necessity of requested services does not meet recognized criteria.
Benefits
- Health, dental & vision insurance that starts day one!
- Prescriptions free of charge through our health plan, beginning day one
- Lowest Cost Benefits!
- Employee Assistance Program (EAP) services
- 401K and Roth with company contribution that starts day one!
- Tuition Assistance
- Referral bonuses
- Term life insurance at no cost to the employee
- Generous paid time off & paid holidays
- Free continuing education and CMEs
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Number of Employees
501-1,000 employees
