Rn Jobs in St Cloud

About The Position

Requirements

• Associate’s degree in nursing from an accredited institution.
• At least three years of experience in clinical utilization management processes.
• Experience in an HMO or managed care setting.
• At least two years of direct, hands-on clinical patient care experience in an acute care facility using an active RN license.
• Advanced knowledge of UM policies, regulations, and processes.
• Advanced knowledge of nationally recognized criteria, including Medicare Local Coverage Determination, Medicare National Coverage Determination, Milliman Care Guidelines, InterQual, and Apollo Managed Care Guidelines/Medical Review Criteria.
• Advanced knowledge of Title 22, Title 10, DMHC, DHCS, CMS, and state regulatory requirements as they relate to UM and Health Plan correspondence.
• Advanced knowledge of clinical nursing practice, standards of care, and medical terminology.
• Advanced knowledge of medical necessity standards and benefit interpretation.
• Strong clinical assessment and documentation skills, including accurate documentation of UM referral reviews.
• Strong written and verbal communication skills.
• Proficiency with computer applications, including word processing, databases, and spreadsheets; proficiency in Microsoft Office Suite.
• Problem-solving skills and the ability to abstract and interpret medical information from clinical records.
• Strong interpersonal skills.
• Ability to communicate information and detailed instructions accurately and quickly to the public and staff.
• Ability to manage a caseload efficiently, set priorities, work productively at speed, and work well under pressure.
• Ability to work independently or as a team member.
• High attention to detail in written and verbal work.
• Ability to work well with physicians and nursing staff, internally and externally.

Nice To Haves

• Bachelor’s degree in nursing from an accredited institution.
• Bilingual English and an IEHP Threshold Language, with written and verbal skills.
• Commercial Plan Coverage experience.
• For internal candidates, preferably two years of experience working in the UM unit.

Responsibilities

• Track inventory, workloads, and staff compliance with prior authorization requests.
• Conduct quality audits of tools completed by UM Nurses and review corrective action plans submitted by delegates.
• Partner with UM Clinical Regulatory leadership to review findings and implement improvements.
• Serve as the primary point of contact for IPAs and delegates placed in concurrent review.
• Communicate approval or rejection of concurrent review files and explain corrections required for files to pass.
• Support UM Nurses by conducting secondary reviews of denial files for potential overturn based on medical necessity and escalate cases for medical director review.
• Maintain advanced knowledge of departmental processes, systems, regulations, and compliance standards.
• Monitor departmental standards, regulatory standards, and processes.
• Collaborate with leadership to evaluate process outcomes, analyze gaps, and escalate concerns to supervisors or management.
• Support leadership in evaluating UM Regulatory & Compliance metrics and their downstream and upstream effects within the department.
• Adhere to and monitor processes established by LEAN events.
• Raise inconsistencies to the leadership management team.
• Participate in developing new processes through LEAN participation.
• Communicate new processes and ensure team adherence.
• Identify training gaps and collaborate with the training team on ongoing training needs.
• Partner with Quality Assurance to identify knowledge gaps.
• Participate in problem-solving gaps within teams and the department.
• Help create efficient workflows, provide feedback on Job Aid development, and assist in validating workflows.
• Continue learning to build and maintain knowledge of IEHP lines of business, products, and system requirements.
• Perform other duties as required to support Health Plan operations and department business needs.

Benefits

• Competitive salary
• On-site state-of-the-art fitness center
• Medical insurance with dental and vision
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs promoting a healthy work-life balance
• Flexible Spending Account for health care and childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance