Utilization Management Nurse

Job Description:

Must:

• Registered Nurse License, active and unencumbered state license in the state where job duties are performed is
• BSN preferred. 2. Four (4) years of clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing.

Duties:

• Utilization Management: Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards. Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.
• Communication: Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.
• Compliance: Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.
• Workflow: Proactively and efficiently work incoming and outbound calls and/or queues from multiple sources within mandated requirements.
• Knowledge: Remain current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.
• Other duties as assigned.

Skills:

• Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding 4.
• Experience in utilization management and/or medical review preferred. S
• Specialized Knowledge & Skills
• Ability to prioritize and make sound nursing judgments through critical thinking
• Excellent verbal and written communication skills
• Ability to build collaborative relationships
• Attention to details
• Ability to interpret complex documentation