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Utilization Management Nurse performs clinical review of prior approvals, network exceptions, benefit inquiries, inpatient medical/surgical admissions and outpatient procedures for providers, and/or 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.
Responsibilities
Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.
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Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards.
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Performs other duties as assigned.
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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.
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Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.
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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.
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Works incoming and outbound calls and/or queues from multiple sources within mandated requirements proactively and effectively.
Requirements
Bachelor's degree in Nursing preferred.
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Registered Nurse (RN) with active, current, unrestricted and recognized in the relevant jurisdiction, state license in good standing in the state(s) where job duties are performed required.
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Minimum four (4) years' clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing.
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Experience in utilization management and/or medical review preferred.
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Oral & Written Communication skills.
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Attention to Detail.
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Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding.
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Ability to prioritize and make sound nursing judgments through critical thinking.
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Ability to build collaborative relationships.
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Ability to interpret complex documentation.
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Ability to work independently.
Nice-to-haves
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Benefits
Tuition reimbursement.
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Club Blue, a free, onsite gym to encourage exercise.
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Green Leaf Grill and Green Leaf Grill Express, onsite restaurants in Little Rock that promote healthy eating.
