RN Utilization Management

Conducts and monitors clinical reviews to assess the medical necessity and appropriateness of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery. Knowledge: Maintain current knowledge of medical and surgical procedures, products, healthcare services, medications, healthcare delivery trends, and applicable organizational procedures, policies, and contracts.

Utilization Management Nurse


Job Summary

Conducts and monitors clinical reviews to assess the medical necessity and appropriateness of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery. Documents relevant information and prioritizes determination requests according to applicable mandates and standards while promoting quality, evidence-based, and cost-effective care.

Responsibilities

• 
  Communication: Collaborate with healthcare providers and internal staff to promote quality of care, cost-effectiveness, accessibility, and appropriate service levels.
  
• 
  Compliance: Practice nursing within the scope of licensure and adhere to policies, procedures, regulations, URAC standards, and applicable state requirements. Make evidence-based decisions that support compliance, appropriate care levels, and patient safety.
  
• 
  Workflow: Efficiently manage incoming and outgoing calls and queues from multiple sources within required timeframes.
  
• 
  Knowledge: Maintain current knowledge of medical and surgical procedures, products, healthcare services, medications, healthcare delivery trends, and applicable organizational procedures, policies, and contracts.
  
• 
  Perform other duties as assigned.
  

Requirements

• 
  Active, unencumbered Registered Nurse license in the applicable state.
  
• 
  Four years of clinical nursing experience in medical-surgical, surgical, intensive care, or critical care nursing.
  
• 
  Bachelor of Science in Nursing preferred.
  
• 
  Experience in utilization management or medical review preferred.
  

Skill

• 
  Proficiency with Microsoft Word, Excel, Outlook, and multiple computer systems.
  
• 
  Ability to prioritize tasks and make sound nursing judgments through critical thinking.
  
• 
  Strong verbal and written communication skills.
  
• 
  Ability to build collaborative relationships.
  
• 
  Strong attention to detail.
  
• 
  Ability to interpret complex documentation.
  

Summary Qualification

• 
  Licensed Registered Nurse with relevant clinical nursing experience.
  
• 
  Knowledge of utilization management, medical necessity review, and healthcare regulations.
  
• 
  Strong clinical judgment and evidence-based decision-making abilities.
  
• 
  Effective communicator with strong organizational and collaboration skills.
  

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.