Schedule Notes: Monday - Friday ; 8am - 4:30pm or 8:30am - 5pm. May have to occasionally adjust schedule to work on weekends, which would be a half day during the weekend and half day during the week to make up for 40 hours. NO OT.
***** Looking for someone with Current licensure as a Registered Nurse in state is required*****
Essential Duties and Responsibilities:
Responsible for the effective and sufficient support of all Utilization Management activities to include prospective/pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies.
Uses an established set of criteria, evaluates and authorizes the medical necessity of some inpatient and outpatient services.
Notifies provider of recommended changes in level of care
Evaluates cases for quality of care and documents quality issues.
Issues letter to provider and member if the service meets certification criteria, and escalates to manager or Medical Director for review if the service does not meet certification criteria, and may issue denial letters.
May participate or assist in the planning of team, UM/QM, PCP, IPA and or Health Plan meetings.
Works with management team to achieve financial goals and operational objectives
Excellent interpersonal and communications skills with clinical staff, management, and all departments involved in the care of our customers
Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments
Ability to make decisions on what needs to be done based on clearly established guidelines
Able to work in a dynamic, fast-paced team environment and to promote team concepts
Substantial knowledge of MS Office including SharePoint, Outlook, PowerPoint, Excel and Word.
At least one year clinical experience.
Excellent communication and interpersonal skills
Excellent time management skills
Working knowledge of the insurance industry and the overall claims process a plus.
Knowledge of UM and CM products
Proficient in basic computer skills
At minimum - Associate's Degree Required
Current licensure as a Registered Nurse in state they will be working in required
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