Job Description:
• Use clinical background to coordinate, document, and communicate all aspects of utilization and benefit management process.
• Ensure members receive the most appropriate level of care while meeting state and federal requirements and turnaround times.
• Involves reviewing clinical documentation, collaborating with providers, and supporting high-quality, cost-effective care.
• Reviewing services for medical necessity and appropriate benefit use.
• Facilitating efficient discharge planning.
• Collaborating with providers and facilities to support members with complex needs.
• Applying clinical skills to assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits.
• Collecting and evaluating clinical information, applying clinical criteria, guidelines, policies, and judgment to make coverage determinations.
• Communicating with providers and external partners to coordinate care and treatment plans.
• Identifying opportunities for referrals to additional programs, services, or care solutions.
• Recognizing opportunities to promote quality care delivery and effective benefit utilization.
• Serving as a resource to internal and external stakeholders regarding UM processes and clinical considerations.
Requirements:
• Active, unrestricted RN license
• 2+ years of acute hospital clinical experience (strong preference for medical-surgical, ICU, behavioral health or other specialty area)
• Strong clinical assessment and decision-making abilities
• Excellent organizational skills with the ability to manage multiple priorities
• Ability to work independently and communicate effectively via phone
• Comfort with computer-based work, multitasking across multiple screens, and documenting while on calls.
• 1+ year of Utilization Review experience (preferred)
• 1+ year of Managed Care experience (preferred)
• Proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook) (preferred)
• Strong telephonic communication skills (preferred)
• Demonstrated ability to exercise sound judgment and collaborate with diverse teams (preferred)
Benefits:
• medical, dental, and vision coverage
• paid time off
• retirement savings options
• wellness programs
• other resources, based on eligibility