Utilization Management Nurse

Job Purpose

The Utilization Management Nurse performs comprehensive clinical reviews of requested services utilizing clinical criteria, received through various mechanisms.

• Initiate referrals to ensure appropriate coordination of care.
• Seek the advice of the Medical Director when appropriate, according to policy.
• Assist non-clinical staff in performance of administrative reviews.
• Perform comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
• Maintain regular and predictable attendance.
• Consistently demonstrate compliance with HIPAA regulations, professional conduct, and ethical practice.
• Work to encourage and promote Company culture throughout the organization.
• Perform other duties as may be assigned.

• 3 years Clinical experience preferred.
• 1-2 years of Utilization Review preferred.
• Proficient in Microsoft Office (Outlook, Word, Excel).
• Working knowledge of NCQA preferred.
• Must be able to work in an independent and creative manner.
• Ability to manage multiple projects and priorities.
• Adaptive to high pace and changing environment.
• Customer service oriented.
• Proficient in interpreting benefits, contract language and medical policy/medical review criteria.
• Current, active Compact State license in Nursing (RN).

Prolonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required.

• 401K (4% Match, Immediate Vesting)
• Accident insurance
• Competitive salary
• Critical Illness Insurance
• Dental Insurance
• Employee Assistance Program
• Flexible Spending Account
• Health & Wellness Program
• Health Savings Account
• Life & AD&D Insurance
• Long Term Disability
• Medical Insurance
• Paid Time Off
• Pet Insurance
• Short Term Disability
• Vision Insurance

Health One is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status, or any other status protected by state or federal law.