Utilization Management Nurse

Paladin Consulting, Inc.

  • Little Rock, AR
  • 7 days ago

    Highlights

    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. Communication: Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.

    Numbers & Facts

    LocationLittle Rock, AR

    Description

    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.
    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
    Education:
    • Registered Nurse License, active and unencumbered state license in the state where job duties are performed is required.
    • 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.

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