DescriptionThe Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
- Active RN license in the state(s) in which the nurse is required to practice
- Previous experience in utilization management required
- Prior clinical experience preferably in an acute care, post-acute, skilled or rehabilitation clinical setting
- Must have good typing skills and proficiency using MS Office Word, Excel and Outlook
- Ability to work independently under general instructions and with a team
- Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required
- Education: BSN or Bachelor’s degree in a related field
- Health Plan experience
- Previous Medicare/Medicaid Experience a plus
- Call center or triage experience
- Previous experience with Milliman (MCG)
- Discharge planning and/or home health or rehab
- Hours for this role are: Monday-Friday 8am-5pm EST or CST
Scheduled Weekly Hours40