Utilization Management Nurse

SIHO HOLDING INC•Columbus, IN

About The Position

This position is for a licensed Registered Nurse who performs Utilization Management (UM) services for SIHO and affiliated business-line members. The role helps ensure health care services are delivered with quality and cost effectiveness and comply with plan guidelines. The UM nurse reviews services prospectively, retrospectively, and throughout episodes of care, making coverage determinations that influence how services are allocated to member populations. The position requires completing quality reviews within strict efficiency standards. The nurse works with members, health care providers, care team members, and the SIHO Medical Director as needed to conduct timely reviews and make appropriate medical-necessity decisions. The role also supports team members, serves as a clinical resource, contributes to quality-improvement efforts, 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 as necessary.
Desire to work in a fast-paced environment focused 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.
Microsoft Office experience, including 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 guidelines established by SIHO and/or 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 support appropriate and timely medical-necessity decisions.
Document the review process using established documentation systems and desk procedures to ensure accurate reporting metrics and data integrity.
Complete case reviews and escalate determinations so they are rendered within SIHO and CMS contractual and regulatory turnaround times.
Assist with 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.
Serve as a clinical resource to the department and other organization 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 early for potential 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 team member within Medical Management for all lines of business and commercial group plans.