Utilization Management Nurse

SIHO Insurance Services•Indianapolis, IN

About The Position

This position is for a licensed Registered Nurse who performs Utilization Management services for SIHO and affiliated business-line members. The role ensures that health care services are administered with quality, cost-effectiveness, and compliance with plan guidelines. Through prospective, retrospective, and concurrent reviews throughout an episode of care, the UM Nurse makes coverage determinations that influence the allocation of services to SIHO member populations. The role requires completing quality reviews within strict efficiency standards. The nurse works with members, health care providers, care team members, and the SIHO Medical Director to complete reviews and make timely medical-necessity decisions. The position also supports accurate documentation and reporting, compliance with contractual and regulatory turnaround times, quality improvement, and identification of members who may benefit from disease or care management programs. The UM Nurse serves as a clinical resource and works as part of an interdisciplinary Medical Management team across lines of business and commercial group plans.

Requirements

Registered Nurse with a current, unrestricted license in the primary state of employment; additional state licenses may be required.
Desire to work in a fast-paced environment with a focus on efficiency while maintaining quality.
Self-directed organization and prioritization skills, and independent time-management skills.
Sound clinical background with experience in the clinical field.
Excellent verbal and written communication skills.
Experience with Microsoft Outlook, Word, and Excel.

Nice To Haves

Previous Utilization Management or health plan experience is highly preferred.

Responsibilities

Conduct pre-service, concurrent, and post-service reviews of health care service necessity using enrollee medical records and established SIHO, state, and federal (CMS) guidelines.
Interact with members, health care providers, and other care team members to complete reviews efficiently.
Consult with the SIHO Medical Director as needed to ensure timely and appropriate medical-necessity decisions.
Document the review process using established systems and desk procedures to support accurate reporting metrics and data integrity.
Complete case reviews and elevate cases for determinations within SIHO and CMS contractual and regulatory turnaround times.
Assist in resolving problems and provide guidance to team members and cohorts.
Interpret and follow organizational policies and procedures, and regularly review work to ensure policies and guidelines are applied appropriately.
Act as a clinical resource for the department and other organizational members on medical management, utilization review, and medical necessity.
Practice within the scope of professional nursing practice and support and participate in departmental quality-improvement strategies and efforts.
Identify and assess members for possible inclusion in disease-management or care-management programs.
Assist in identifying and reporting Potential Quality of Care concerns and Fraud, Waste and Abuse incidents.
Work as an interdisciplinary Medical Management team member across all lines of business and commercial group plans.