PR:$50/hr-$53/hr

About the Role:

• We are looking for a Utilization Management Nurse to join our team.
• The primary responsibility of this role is to conduct inpatient medical necessity/utilization review and other utilization management activities to ensure that Healthcare members receive the appropriate care at the right time and place.
• The role involves daily evaluation of members requiring hospitalization or procedures, providing prior authorizations, and ensuring compliance with state and federal regulations.

Responsibilities: -

• Conduct concurrent review and prior authorizations for Client members as part of the Utilization Management team
• Determine appropriate benefits, eligibility, and expected length of stay for members seeking treatments or procedures
• Collaborate with other departments to enhance continuity of care for Client members
• Maintain department productivity and quality measures
• Attend staff meetings and assist in mentoring new team members
• Complete assigned work plan objectives and projects in a timely manner
• Maintain professional relationships with providers and internal/external customers
• Consult with client medical directors and refer cases as needed
• Ensure compliance with workplace safety standards

Education Qualification: -

• Completion of an accredited Registered Nursing program (a combination of experience and education may be considered in lieu of a Registered Nursing degree)

Required Skills: -

• Minimum 8-10 years of clinical practice, preferably in hospital nursing, utilization management, or case management
• Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing
• Ability to communicate effectively, problem solve, and work well with others
• Strong organizational skills and ability to manage multiple priorities
• Knowledge of state and federal regulations, Interqual, and other references for medical necessity determinations
• Experience with NCQA
• Ability to work independently and handle multiple projects simultaneously
• Proficiency in MS Office products
• Excellent verbal and written communication skills
• Ability to abide by company policies, maintain confidentiality, and comply with HIPAA regulations
• Skilled at establishing and maintaining positive work relationships with coworkers, clients, members, providers, and customers.