UM BH Registered Nurse
About The Position
This internship is for transitioning military service members or military spouses looking to gain experience in healthcare. The DOW SkillBridge Internship and Military Spouse Fellowship Programs will provide main training for the internship. Interns will partner with their team to support members, projects, and meet goals affecting outcomes. Professionals encountered may include healthcare professionals, HR, and IT. The objective is to support and facilitate care for members. To be eligible, candidates must be a transitioning military service member or a military spouse and eligible for the DOW sponsored programs. The Utilization Management Behavioral Health Registered Nurse (RN) Intern will report to a manager of the National Medicaid team. They will use training and acquired skillsets to complete medical necessity reviews for behavioral health requested services using clinical judgment and provide referrals to internal stakeholders for further review depending on case findings.
Requirements
- Must be a transitioning service member eligible to participate in the DOW SkillBridge or a military spouse eligible to participate in the military spouse fellowship.
- Active Registered Nurse, RN, in the state of Kentucky or an enhanced Compact, (eNLC) license without restrictions or disciplinary action.
- Minimum two (2) years of clinical behavioral health experience.
- Proficiency in healthcare software and electronic medical records (EMR) systems.
- Interest in working in the managed care industry.
Nice To Haves
- Bachelor's degree
- Previous Medicare/Medicaid experience.
- Previous experience in prior authorization, utilization management.
- Experience working with MCG or Interqual guidelines.
- Certification in Case Management, (CCM) or Utilization Review, (UR).
- Knowledge of payer policies, insurance companies and government health programs.
Responsibilities
- Conduct comprehensive clinical reviews of prior authorization requests to determine medical necessity and benefit eligibility.
- Apply advanced evidence-based clinical guidelines in review decisions.
- Ensure compliance with accreditation, state, and federal regulations.
- Communicate with healthcare providers to obtain necessary clinical information and clarify requests.
- Coordinate with medical directors and interdisciplinary teams to support decision-making.
- Promote communication between clinicians, internal departments, and members.
- Document all review findings and decisions in clinical documentation systems.
- Ensure timely and accurate documentation of prior authorization determinations.
- Support reporting programs and provide data for performance improvement projects.
- Implement quality assurance measures to ensure accuracy and consistency in prior authorization decisions.
- Conduct regular audits and reviews to maintain high standards of service.
- Identify process improvement opportunities and contribute to performance improvement projects.
- Educate providers and staff on prior authorization policies, criteria, and review processes.
- Provide mentorship and feedback to nonclinical staff and peers to enhance workflow efficiency.
- Stay current with clinical best practices and regulatory changes.
- Use skills to make an impact.
Benefits
- Networking opportunities will be provided while participating in the Internship or Fellowship.
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What This Job Offers
Career Level
Intern
Education Level
Associate degree
