Registered Nurse, UM – Physical Health
About The Position
Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives. Trillium Health Resources has a career opening for a Registered Nurse to join our Utilization Management team! The Registered Nurse, UM – Physical Health, is responsible for ensuring timely and accurate determination and notification of reviews and reconsiderations based on the review determination status. The Registered Nurse, UM – Physical Health, will generate approval, modifications, and denials communications, to include member and provider notification of review determination. This position also facilitates, coordinates, and approves medically necessary reviews that meet established criteria.
Requirements
- Fully licensed by the North Carolina State Board of Nursing as an RN.
- Minimum one (1) year of clinical nursing experience.
- Must have a valid driver’s license.
- Must reside within North Carolina.
- Must be able to travel within catchment as required.
Nice To Haves
- Bachelor’s degree in nursing.
- One (1) to two (2) years of experience in utilization management or managed care setting.
- Utilization Management certification.
Responsibilities
- Perform prospective/preservice, concurrent, post-service, and retrospective claims medical review processes. Utilizing considerable clinical judgement, independent analysis, critical-thinking skills, and detailed knowledge of clinical coverage policies, clinical practice guidelines, and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identify cases needing Medical Director review or input. Present cases to Medical Director for potential review or determinations when needed.
- Perform telephonic admission and concurrent review, and collaborate with on-site facility staff, physicians, providers, care management, 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 and/or claims systems.
- Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.
Benefits
- Typical working hours: 8:30 am – 5:00 pm; flexible work schedules with some roles with management approval.
- Work-from-home options available for most positions
- Health Insurance with no premium for employee coverage
- Flexible Spending Accounts
- 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year
- NC Local Government Retirement Pension (defined-benefit plan)
- 401k with 5% employer match and immediate vesting
- Public Service Loan Forgiveness (PSLF) qualifying employer
- Quarterly stipend for remote work supplies
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
501-1,000 employees
