Utilization Management Nurse

Job Title: Utilization Management Nurse Consultant

Duration: 6 months (Possible ext)

Location: Downers Grove, IL

Responsibilities:

· Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities.

· Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work.

· Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.

· Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Requires an RN (consideration for LCSW) with unrestricted active license.

· Fundamental Components & Physical Requirements include but are not limited to

· (* denotes essential functions)

· Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members

· Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care

· Communicates with providers and other parties to facilitate care/treatment

· Identifies members for referral opportunities to integrate with other products, services and/or programs

· Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization

· Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function

· Background/Experience Desired

· Managed Care experience preferred

· 3-5 years of clinical experience required

· Education and Certification Requirements

· RN consideration for LCSW) with current unrestricted state license required.

· Additional Information (situational competencies, skills, work location requirements, etc.)

· Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding

· Effective communication skills, both verbal and written.

· Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

· Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.

· Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.

· Typical office working environment with productivity and quality expectations

· Additional for Behavioral Health:

· Experience in Behavioral Health required

· Managed Care experience preferred.

· Onsite location will be Downers Grove.

· Work hours from 8:00 am until 5:00 pm with weekend rotation among the team of clinicians (approximated to rotate once every 1 & ½ to 2 months).

· The ability to create and process clinical for Behavioral Health cases on a live phone queue, create and process clinical to of a determination to the provider.

Additional Job Details:

· Required to have computer skills.

· Work with-toggle between up to 5-6 applications/systems at a time.

· Travel Required: No

n/a

Kind Regards

Sumit Agarwal

732-902-2125