Utilization Management- RN

South Country Health Alliance•Medford, MN

23h•Hybrid

About The Position

South Country Health Alliance is seeking a Utilization Management RN to join our team! The RN Utilization Management nurse is a member of the UM team responsible for conducting medical necessity reviews for pre-service/prior authorization, post-service/retrospective reviews, and other assigned utilization reviews based on product requirements, service type, and organizational workflow. This role reviews clinical information, applies appropriate medical necessity criteria, and ensures coverage determinations are completed accurately and within required regulatory and organizational timeframes. The UM RN works collaboratively with providers, medical directors, internal departments, and other stakeholders to support appropriate, timely, and member-centered care. This position involves a rotating on-call schedule, as required, to meet departmental and regulatory time frames during weekends and holidays.

Requirements

Current, valid, and unrestricted Minnesota RN License.
Requires a minimum of 3 years' clinical experience in a health care setting.
Experience with Microsoft Office Suite.
Strong written and verbal communication skills.
Ability to multitask and balance priorities.
Must be legally authorized to work in the U.S. (No sponsorship available)

Nice To Haves

Previous utilization management experience
Experience in interpreting managed care benefit plans
Strong knowledge of government programs (Medicare and Medicaid)
Experience interpreting and applying established clinical review criteria and guidelines such as State and Federal guidelines, InterQual, or internal health plan policies.
Experience with telephonic communication and provider follow-up.

Responsibilities

Accurately and consistently perform pre-service, concurrent, and post-service clinical reviews by applying established medical necessity criteria, guidelines, benefit requirements, and organizational policies.
Utilize clinical judgment to evaluate treatment appropriateness and level of care, document review determinations clearly and in compliance with regulatory and professional standards and prepare and escalate cases to the Medical Director when required.
Collaborates with members, clinic/hospital staff and other providers effectively to identify and obtain additional clinical information as needed to support complete, timely, and accurate review decisions within turnaround time requirements for all products.
Maintains assigned workload and completes responsibilities within timelines established by regulatory requirements and departmental policies and procedures.
Incorporates quality by identifying opportunities for refinement or improvement of the UM program, participating in continuous improvement process efforts, and successfully completing annual regulatory inter-rater reliability testing.
Displays understanding of the organization’s products, benefits, provider network, and contracts, ensuring the member receives services through contracted providers as appropriate and available while minimizing out-of-network migration whenever possible.
Collaborates with claims, the provider contact center, provider relations, and contracting on ad hoc provider education activities, and participates in committees or work groups as needed.
Performs other duties as assigned.