RN Utilization Management remote - MediGold Health Plan

Trinity Health•Columbus, OH

2d•Remote

About The Position

RN Utilization Management MCHP is responsible for the coordination of the medical care provided to Plan members with Plan providers, the member's family and other resources as appropriate. Assist in the development of the Plan's UM Program and the review of the Plan's Utilization Management Plan.

Requirements

Education: Associate or Bachelor's Degree in Nursing
Licensure / Certification: RN with current unrestricted state licensure required, nursing compact license is preferred. Ability to obtain licenses from other participating states
Experience: Minimum of 5-7 years of clinical nursing experience. 2 years’ experience in prior authorization, utilization review, hospital appeals or case management preferred.
Effective Communication Skills
Demonstrated ability to analyze, summarize and concisely report medical utilization and medical chart audit results.
Proven ability to work independently, with attention to accuracy and consistency of information obtained and recorded.
PC computer skills required.
Ability to compare approved criteria with clinical information to determine appropriateness of service and to document all related information according to department policies and procedures

Responsibilities

Participates in designated committees and task forces according to the UM Program and at the direction of the Director, Utilization Management.
Coordinates with the utilization review, case management, discharge planning staff within network facilities.
Coordinates with Medical Director/Associate Medical Directors on case-specific issues.
Coordinates with Claims, Member Services, Grievance Coordinator and other operational departments regarding case management issues.
Documents and communicates to QM staff appropriately all identified quality concerns related to Members.
All other duties as assigned.

Benefits

Mount Carmel Health System recognized by Forbes in 2025 as one of America’s Best State Employers.
Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
Retirement savings account with employer match starting on day one.
Generous paid time off programs.
Employee recognition programs.
Tuition/professional development reimbursement starting on day one.
RN to BSN tuition 100% paid at Mount Carmel’s College of Nursing.
Relocation assistance (geographic and position restrictions apply).
Employee Referral Rewards program.
Mount Carmel offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. You deserve to get paid every day!
Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.