Utilization Management Registered Nurse, Michigan

McLaren Health Care • Flint, MI

121d

About The Position

We are looking for a Utilization Management RN, to join us in leading our organization forward. McLaren Integrated HMO Group (MIG) is a fully owned subsidiary of McLaren Health Care Corporation and is the parent company of McLaren Health Plan in Michigan and MDwise, Inc. in Indiana. It is an organization with a culture of high performance and a mission to help people live healthier and more satisfying lives. McLaren Health Plan and MDwise, Inc., subsidiaries of MIG, value the talents and abilities of all our employees and seeks to foster an open, cooperative and dynamic environment in which employees and the health plans can thrive. As an employee of MIG, you will be a part of a dynamic organization that considers all our employees as leaders in driving the organization forward and delivering quality service to all our members. McLaren Health Plan is our Michigan-based health plan dedicated to meeting the health care needs of each of our Michigan members. Learn more about McLaren Health Plan at https://www.mclarenhealthplan.org. MDwise is our Indiana-based health plan, working with the State of Indiana and Centers for Medicare and Medicaid Services to bring you the Hoosier Healthwise and Healthy Indiana Plan health insurance programs. Learn more about MDwise, Inc. at https://www.mdwise.org.

Requirements

• RN with a valid unrestrictive license from state employed in state providing services.
• Two (2) years clinical nursing experience.
• One (1) year previous experience in Managed Care Utilization Management, Medical Management, Case Management.

Nice To Haves

• Two (2) years’ experience and knowledge of HMO, PPO, TPA, PHO and Managed Care functions including understanding of claims administration, including CPT-4 codes, revenue codes, HCPCS codes, DRGs, etc.
• Two (2) years’ experience in Managed Care Utilization Management, Medical Management, Case Management.
• BSN.
• Certified Case Manager (CCM) Certification.

Responsibilities

• Responsible for utilization management functions including review and authorization of services.
• Utilization of medical policy and standard screening techniques.
• Utilization of behavioral change techniques.
• Work with the PCP, the member, and management to promote the delivery of quality services at the most appropriate and cost-effective setting.
• Act as the member advocate with emphasis on education regarding managed care, disease management, and PCP treatment plans.
• Monitor member’s utilization patterns for identification of high risk, and under and overuse of services.
• Collaborate with Medical Director and senior management on complex cases and special projects.

What This Job Offers