Utilization Management Nurse I

Job Description

Use Your Strengths at Wellmark as a Utilization Management Nurse! 

About the role: As a Utilization Management (UM) Nurse, you will provide UM services, transition of care and support to members and health care providers. You will utilize clinical knowledge and expertise to interpret and appropriately apply medical policy, medical necessity criteria (InterQual), and benefit information to provide consultation and responses to UM requests. You will proactively assess and assist members to help move them through the continuum of care by utilizing services and resources efficiently. You will be part of a multidisciplinary team to continuously look for ways to improve processes and maximize health dollars for our members.  

About you: Are you a dedicated, compassionate and detail-oriented health care professional with the ability to adapt to change and anticipate needs? Are you organized, inquisitive, and thrive in a collaborative setting, while exhibiting independent and critical thinking where resourcefulness is key? Are you motivated and inspired by the opportunity to utilize your clinical expertise in a fast-paced production environment with quality goals? Do you enjoy a team-centric environment where relationship building and strong communication skills are crucial to success? If so, apply today! 

Candidates located in Iowa or South Dakota preferred. Top candidates will have prior health plan and/or UM experience along with a diverse clinical background. Prior remote work experience a plus! 

Must be flexible and have the ability work weekend and/or holiday hours when needed on a rotational basis.

Qualifications

Required Qualifications:

• Completion of an accredited nursing program or licensed practical nursing program.
• Active and unrestricted RN or LPN license in Iowa or South Dakota. Individual must be licensed in the state in which they reside.
• 4+ years of diverse clinical experience (e.g. acute care, outpatient, home health, etc.) that reflects 4+ years of direct clinical care to the consumer. Experience in utilization management or health insurance setting beneficial.
• Previous experience working independently and managing an assigned caseload.
• Strong verbal communication skills; influences action and facilitates crucial conversations regarding care with members, physicians, and care facilities.
• Strong written communication skills, including accurate documentation of events within the care management platform; ensures quality and consistency by following guidelines and processes.
• Commitment to service excellence and member advocacy; uses critical thinking and problem-solving skills to anticipate and act on member/provider needs.
• Resourceful self-starter who demonstrates strong understanding of resources, processes, and guidelines. Able to make independent decisions or recommendations under ambiguity.
• Ability to organize and manage multiple priorities in a dynamic work environment where quality and/or production goals are measured. Commitment to timeliness, follow up, accuracy and attention to detail. Flexible and adapts to change.
• Develops collaborative relationships with peers, team members and stakeholders; viewed as a trusted partner.
• Maintains courtesy and professionalism when engaging with members and providers, internal and external stakeholders.
• Strong technical acumen; learns new systems quickly – e.g., Microsoft Office, clinical documentation platforms, etc.

Preferred Qualifications:

• Active and unrestricted RN license in Iowa or South Dakota.