Utilization Management Nurse

Job Description

Job Title: Utilization Management Nurse Consultant

Duration: 6 months (Possible ext)

Location: Downers Grove, IL

Responsibilities:

·Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities.

·Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work.

·Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.

·Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Requires an RN (consideration for LCSW) with unrestricted active license.

·Fundamental Components & Physical Requirements include but are not limited to

·(* denotes essential functions)

·Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members

·Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care

·Communicates with providers and other parties to facilitate care/treatment

·Identifies members for referral opportunities to integrate with other products, services and/or programs

·Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization

·Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function

·Background/Experience Desired

·Managed Care experience preferred

·3-5 years of clinical experience required

·Education and Certification Requirements

·RN consideration for LCSW) with current unrestricted state license required.

·Additional Information (situational competencies, skills, work location requirements, etc.)

·Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

·Effective communication skills, both verbal and written.

·Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

·Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.

·Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.

·Typical office working environment with productivity and quality expectations

·Additional for Behavioral Health:

·Experience in Behavioral Health required

·Managed Care experience preferred.

·Onsite location will be Downers Grove.

·Work hours from 8:00 am until 5:00 pm with weekend rotation among the team of clinicians (approximated to rotate once every 1 & ½ to 2 months).

·The ability to create and process clinical for Behavioral Health cases on a live phone queue, create and process clinical to of a determination to the provider.

Additional Job Details:

·Required to have computer skills.

·Work with-toggle between up to 5-6 applications/systems at a time.

·Travel Required: No

Qualifications

n/a

Additional Information

Kind Regards

Sumit Agarwal

732-902-2125