Position Summary
Utilization Management is a 24/7 operation and the work schedule may include weekends, holidays, and evening hours.
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.
Typical office working environment with productivity and quality expectations.
Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
Sedentary work involving periods of sitting, talking, listening.
Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.
Effective communication skills, both verbal and written
Required Qualifications
- 3+ years of experience as a Registered Nurse
- Must have active current and unrestricted RN licensure in state of residence
- Must possess 1+ years of clinical experience in acute or post acute setting
- Utilization Management is a 24/7 operation and the work schedule may include weekends, holidays, and evening hours.
Preferred Qualifications
- Managed Care experience preferred
Education
Associates Degree minimum
BSN preferred