UM Clinical Specialist RN-Physical Health (Full Time, Remote, North Carolina Based)

Alliance Health•Durham, NC

28d•$69,592 - $88,729•Remote

About The Position

The Utilization Management (UM) Clinical Specialist RN for Physical Health independently assesses the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, and out-of-network services. The role monitors consumer treatment through ongoing review to ensure services are based on consumer need and established clinical guidelines, and identifies and follows up on clinical cases of concern and high-risk or special-needs consumers to connect enrollees with appropriate treatment resources. The specialist may represent the unit in cross-agency collaborative needs. The position is primarily remote, with no routine expectation of working in the office. Attendance at the Alliance Office is required for business and team meetings as needed. The role conducts medical necessity and utilization reviews, supports compliance with applicable policies and standards, coordinates UM processes, and collaborates with internal departments, providers, consumers, community agencies, and other stakeholders.

Requirements

Graduation from a state-accredited school of nursing or an Associate's Degree in Nursing from an accredited institution, plus five years of nursing experience; alternatively, a Bachelor's degree in Nursing from an accredited college or university, plus three years of nursing experience.
Current, active, and unrestricted North Carolina clinical license as a Registered Nurse, or a compact license.
Knowledge of physical health and comorbid health conditions.
Knowledge of diagnostic treatment guidelines and protocols, and level-of-care criteria.
Proficiency using computers and multiple software programs.
Written and oral communication skills.
Ability to interact with a wide variety of individuals and handle complex, confidential, and sensitive situations.
Knowledge of Utilization Management managed care principles and strategies.
Ability to analyze process effectiveness and adjust developed processes.
Knowledge of and experience in acute clinical utilization review.
Knowledge of authorization and re-authorization Utilization Management standards.
Knowledge of related duties in patient care delivery, management of patient care providers, or project management in a healthcare environment.
Ability to lead, delegate, and problem solve.
Ability to develop and document workflows.
Ability to assist with appeals when medical care is denied by payor entities, in a timely fashion.
Knowledge of and experience with NCQA.

Nice To Haves

Experience in Utilization Management.

Responsibilities

Independently conduct medical necessity reviews of provider service requests against established clinical guidelines within contractually mandated turnaround times.
Ensure authorized services address appropriate service needs, intensity of service, outcomes, and alternatives for consumers.
Apply medical necessity criteria consistently for physical health services while promoting a holistic review of member needs.
Conduct pre-certification, concurrent, and retrospective reviews for compliance with medical policy, member eligibility, benefits, and contracts.
Conduct utilization reviews to monitor adherence to clinical practice guidelines and best-practice standards.
Notify members of adverse benefit determinations while preserving their Due Process rights.
Ensure compliance with performance measures outlined in accrediting body standards.
Perform other related duties as required by the immediate supervisor or designated Alliance Health administrators.
Comply with utilization management and quality improvement policies and procedures, utilization review laws and regulations, and state standards.
Support the Utilization Management Department's focus on timeliness, effectiveness, quantity, quality, and cost of services for eligible enrollees.
Participate in integrating the department and its functions into the organization's primary mission.
Collaborate within the Utilization Management Department to support integration between Physical Health and Behavioral Health.
Monitor for undesirable performance or deviations from practice standards that may negatively affect consumers.
Follow up with consumers and providers, provide provider technical assistance, and/or refer matters to other MCO departments as appropriate.
Maintain open and timely communication with staff, providers, community agencies, and other stakeholders.