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Job Summary

The RN Utilization Management Nurse performs clinical review of prior approvals, network exceptions, benefit inquiries, inpatient medical/surgical admissions and outpatient procedures for providers, and all other contracted lines of business. This role assesses and evaluates the efficiency and appropriateness of services for medical necessity through interpretation and review with evidenced-based criteria, clinical guidelines, corporate guidelines and policies and mandates and standards. Incumbent also facilitates and promotes appropriate care and quality toward cost effective and cost containment measures based on evidence. This role is responsible for providing utilization management services over the weekend, outside of normal business week hours.

Requirements

EDUCATION
Bachelor's degree in Nursing preferred.

LICENSING/CERTIFICATION
Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required.

EXPERIENCE
Minimum four (4) years' clinical practice nursing experience consisting of some experience in each of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing.
Experience in utilization management and/or medical review required.

Note: Employees meeting these qualifications and accepting this role with this schedule will be provided a $ 5,000 premium added to their base salary.

ESSENTIAL SKILLS & ABILITIES
Oral & Written Communication
Attention to Detail
Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding.
Ability to prioritize and make sound nursing judgments through critical thinking.
Ability to build collaborative relationships.

Skills

• Active Listening
• Analytical Decision Making
• Critical Thinking
• Data Analysis
• Educational Development
• Interpersonal Relationship Management
• Microsoft Outlook
• Microsoft SharePoint
• Microsoft Word
• Oral Communications
• Problem Sensitivity
• Sound Judgment
• Team Development
• Time Management
• Written Communication

Responsibilities

• Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.
• Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-ofnetwork services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards.
• 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.
• Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.
• Provides primary utilization management review and communication for both scheduled workdays during the regular workweek AND scheduled weekend period.
• Remains 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.
• Works incoming and outbound calls and/or queues from multiple sources within mandated requirements proactively and effectively.

Certifications

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

2.1 General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of location of primary work assignment as essential functions of the job.