Utilization Management Nurse
About The Position
This position is reserved for a licensed Registered Nurse who will perform the Utilization Management (UM) services for SIHO (and affiliated business lines’) members. This individual’s primary role is to ensure that health care services are administered with quality, cost effectiveness, and compliance to plan guidelines. By performing review of services prospectively, retrospectively, and throughout the episode of care, the UM nurse will make coverage determinations influencing how services are allocated to SIHO’s various member populations. A candidate’s ability to perform quality reviews within strict efficiency standards is required for this position.
Requirements
- Registered Nurse with current, unrestricted license in primary state of employment (position may require additional licensing in other states as necessary)
- Desire to work in a fast-paced environment with focus on efficiency and attention to detail while maintaining quality
- Self-directed organizational and prioritization skills, and independent time management skills required
- Sound clinical background with experience in the clinical field
- Excellent verbal and written communication skills
- Microsoft Office Experience: Outlook, Word, Excel
Nice To Haves
- Previous UM or Health Plan experience highly preferred
Responsibilities
- Pre-service, concurrent, and post-service review for medical necessity of health care services utilizing enrollee medical records and established guidelines set by SIHO and/or state and federal (CMS) guidelines
- Interaction with the member, health care provider, and/or other care team members to complete reviews in most time-efficient manner
- Interaction with the SIHO Medical Director or external Medical Reviewers as needed to ensure proper medical necessity decisions are made in a timely manner
- Appropriate documentation of the entire review process utilizing the established documentation system and desk procedures to guarantee accurate reporting metrics and data integrity
- Complete case review and manage turnaround times to assure determinations are rendered within the contractual and regulatory turnaround times established by SIHO and CMS
- Assist in problem resolution and provide guidance to members of the team and cohorts
- Interpret and abide by organizational policies and procedures; review work regularly to ensure that policies and guidelines are appropriately applied
- Act as a clinical resource to the department and other organization members for services pertaining to medical management, utilization review, and medical necessity
- Act and perform within the scope of professional nursing practice; display responsibility in supporting and participating in department strategies and efforts focused on quality improvement
- Responsible for the early identification and assessment of members for inclusion in disease management or care management programs
- Assist in the identification and reporting of Potential Quality of Care concerns and Fraud, Waste and Abuse incidents
- Work as an interdisciplinary team member within Medical Management for all lines of business and commercial group plans
- Show effective prioritization, efficiency and accuracy of work product in alignment with department goals.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
