This is a remote position.
The Utilization Management (UM) Nurse is responsible for conducting clinical reviews and assessing the medical necessity appropriateness and efficiency of healthcare services requested by providers and members. This role supports the health plans utilization management functions in alignment with clinical guidelines plan benefits regulatory requirements and accreditation standards.
The UM Nurse ensures the delivery of cost-effective high-quality care for members through a variety of activities including utilization review of inpatient outpatient and ancillary services using standardized clinical criteria such as MCG and InterQual.
Requirements
Candidates must hold an Associate Degree in Nursing and maintain an active unrestricted Registered Nurse (RN) license in the applicable state or possess a compact license.
A minimum of three years of prior experience in utilization management within a health insurance company is required.
Strong familiarity with MCG InterQual or CMS criteria is essential as is a working knowledge of UM-related regulatory and accreditation standards such as CMS NCQA and URAC.
The role requires advanced clinical judgment critical thinking and communication skills along with proficiency in electronic medical records and utilization management systems.
Preferred qualifications include a Bachelors Degree in Nursing and professional certification in Case Management or Utilization Review such as CCM CPUR or CPUM.
Experience using UM platforms such as TruCare GuidingCare Jiva or similar systems is desirable along with previous involvement in appeals grievances concurrent review or behavioral health utilization management.
A multistate compact RN license is also preferred.
Benefits
Contract Work
Required Skills:
Minimum Qualifications: * Degree/Education: Bachelors of Science in Nursing. Graduate from a college or university accredited by National League for Nursing Accrediting Commission (NLNAC) or The Commission on Collegiate Nursing Education (CCNE) or the Commission on Graduates of Foreign Nursing Schools (CGFNS). * Experience: Minimum of three (3) years experience as a clinical nurse in the medical/surgical or critical care inpatient setting. Experience with newborn to geriatric population. Minimum of 1 year of experience in post anesthesia/sedation. * Licensure: Current full active and unrestricted license to practice as a Registered Nurse from any state. * Life Support Certification:Basic Life Support (BLS) Advanced Cardiac Life Support (ACLS) or Advanced Life Support (ALS) Pediatric Advanced Life Support (PALS) and Trauma Nursing Core Course (TNCC) certifications are required. * Security: Must possess ability to pass a Government background check/security clearance.
This is a remote position. The Utilization Management (UM) Nurse is responsible for conducting clinical reviews and assessing the medical necessity appropriateness and efficiency of healthcare services requested by providers and members. This role supports the health plans utilization management...
This is a remote position.
The Utilization Management (UM) Nurse is responsible for conducting clinical reviews and assessing the medical necessity appropriateness and efficiency of healthcare services requested by providers and members. This role supports the health plans utilization management functions in alignment with clinical guidelines plan benefits regulatory requirements and accreditation standards.
The UM Nurse ensures the delivery of cost-effective high-quality care for members through a variety of activities including utilization review of inpatient outpatient and ancillary services using standardized clinical criteria such as MCG and InterQual.
Requirements
Candidates must hold an Associate Degree in Nursing and maintain an active unrestricted Registered Nurse (RN) license in the applicable state or possess a compact license.
A minimum of three years of prior experience in utilization management within a health insurance company is required.
Strong familiarity with MCG InterQual or CMS criteria is essential as is a working knowledge of UM-related regulatory and accreditation standards such as CMS NCQA and URAC.
The role requires advanced clinical judgment critical thinking and communication skills along with proficiency in electronic medical records and utilization management systems.
Preferred qualifications include a Bachelors Degree in Nursing and professional certification in Case Management or Utilization Review such as CCM CPUR or CPUM.
Experience using UM platforms such as TruCare GuidingCare Jiva or similar systems is desirable along with previous involvement in appeals grievances concurrent review or behavioral health utilization management.
A multistate compact RN license is also preferred.
Benefits
Contract Work
Required Skills:
Minimum Qualifications: * Degree/Education: Bachelors of Science in Nursing. Graduate from a college or university accredited by National League for Nursing Accrediting Commission (NLNAC) or The Commission on Collegiate Nursing Education (CCNE) or the Commission on Graduates of Foreign Nursing Schools (CGFNS). * Experience: Minimum of three (3) years experience as a clinical nurse in the medical/surgical or critical care inpatient setting. Experience with newborn to geriatric population. Minimum of 1 year of experience in post anesthesia/sedation. * Licensure: Current full active and unrestricted license to practice as a Registered Nurse from any state. * Life Support Certification:Basic Life Support (BLS) Advanced Cardiac Life Support (ACLS) or Advanced Life Support (ALS) Pediatric Advanced Life Support (PALS) and Trauma Nursing Core Course (TNCC) certifications are required. * Security: Must possess ability to pass a Government background check/security clearance.
View more
View less
Job Location:
Monthly Salary:
Experience Required:
Posted on:
30+ days ago
Vacancies:
1 Vacancy
