Utilization Management Correspondence RN

Amerihealth Caritas•,

19h•Remote

About The Position

The Utilization Management Correspondence Registered Nurse (RN) works under the direction of the Utilization Management Operations Administrative Supervisor. The role creates, writes, edits, and completes utilization management review adverse decision notices and other informational letters in accordance with applicable state and plan requirements and required timeframes. The RN oversees behavioral and physical health approval and denial letters for Medicaid, Medicare, and Exchange products. The position applies regulatory, accreditation, departmental, medical health benefit policy, and medical management standards to ensure letters appropriately justify authorized services and denials when guidelines are not met. The RN maintains current knowledge of applicable laws, regulations, DHS/NCQA requirements, and policies, and reports noncompliance or trends to leadership as appropriate. This is a remote role, scheduled Monday through Friday from 8:00 a.m. to 5:00 p.m. EST. Availability to work rotating weekends based on business needs is required, as is working four of ten rotating holidays, including Thanksgiving and Christmas. Remote work requires reliable high-speed internet of at least 50 Mbps download and 5 Mbps upload.

Requirements

Bachelor’s degree.
Registered Nurse.
At least 3 years of diverse and independent clinical practice experience as a Registered Nurse.
At least 2 years of experience conducting inpatient, outpatient, and post-acute utilization management reviews for a payor.
Utilization management review experience in a managed care organization.
Experience applying NCQA, individual state contract, and CMS regulatory standards throughout the review process.
Quality assurance or auditing experience in a managed care organization or acute care setting.
Active and unencumbered Enhanced Nurse Licensure Compact (eNLC) required.
Ability to meet productivity measures in a high-volume work environment.
Strong analytical, data interpretation, written communication, and verbal communication skills.
Decision-making skills, including the ability to identify problems and recommend solutions.
Detail-oriented and process-driven.

Responsibilities

Navigate the documentation system, currently JIVA, and understand the utilization management review process for medical necessity determinations and the Medical Director rationale for determinations.
Ensure letters meet Code of Federal Regulations requirements, including appropriate readability, grammar, and accurate dates.
Ensure the translation process is followed when a member’s language preference is other than English.
Collaborate with Medical Directors when rationale needs updating to meet regulatory requirements.
Apply regulatory, accreditation, departmental, medical health benefit policy, and medical management standards to approval and denial letters.
Maintain current knowledge of applicable laws, regulations, DHS/NCQA requirements, and policies.
Report noncompliance or other trends to leadership as appropriate.