Utilization Management Nurse

Primary Responsibilities

Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures.

Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.

Collaborates with healthcare partners to ensure timely review of services and care.

Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed.

Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards

Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.

Triages and prioritizes cases and other assigned duties to meet required turnaround times.

Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations.

Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements.

Duties as assigned.

Essential Qualifications

Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment.

Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)

Must be able to work independently.

Must be detail oriented and have strong organizational and time management skills.

Adaptive to a high pace and changing environment- flexibility in assignment.

Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.

Proficient in MCG and CMS criteria sets

Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.

Working knowledge of URAC and NCQA.

2+ years’ experience in a UM team within managed care setting.

3+ years’ experience in clinical nurse setting preferred.

TPA Experience preferred.