Utilization Management Nurse

HealthOne Alliance•Dalton, GA

2d•Onsite

About The Position

The Utilization Management Nurse performs comprehensive clinical reviews of requested services utilizing clinical criteria, received through various mechanisms.

Requirements

3 years Clinical experience preferred
1-2 years of Utilization Review preferred
Proficient in Microsoft Office (Outlook, Word, Excel)
Working knowledge of NCQA preferred
Must be able to work in an independent and creative manner.
Ability to manage multiple projects and priorities
Adaptive to high pace and changing environment
Customer service oriented
Proficient in interpreting benefits, contract language and medical policy/medical review criteria
Current, active Compact State license in Nursing (RN).

Responsibilities

Initiate referrals to ensure appropriate coordination of care.
Seek the advice of the Medical Director when appropriate, according to policy.
Assists non-clinical staff in performance of administrative reviews
Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
Regular and predictable attendance
Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
Works to encourage and promote Company culture throughout the organization
Other duties as may be assigned