UM Clinical Specialist, RN – Physical Health
Job in
Morrisville, Wake County, North Carolina, 27560, USA
Listed on 2026-07-31
Listing for:
Jobtailor
Full Time
position Listed on 2026-07-31
Job specializations:
-
Nursing
Healthcare Nursing, Clinical Nurse Specialist, RN Nurse, Nurse Practitioner
Job Description & How to Apply Below
- Assesses the medical necessity of services
- Independently conduct medical necessity reviews of service requests
- Ensure authorized services address service needs, intensity of service outcomes, and alternatives for consumers
- Conduct pre-certification, concurrent, and retrospective reviews to ensure compliance
- Conduct utilization reviews to monitor adherence to clinical practice guidelines
- Notify members of adverse benefit determinations while preserving members' Due Process rights
- Ensure compliance with performance measures outlined within all accrediting body standards
- Graduation from a State accredited school of nursing or an Associate's Degree in Nursing from an accredited
- 5 years of nursing experience OR Bachelor's degree in Nursing from an accredited college/university and 3 years of nursing experience
- Current, active, and unrestricted North Carolina clinical license as a Registered Nurse, or a compact license
- Experience in Utilization Management
- Knowledge of physical health and co-morbid health conditions
- Knowledge of diagnostic treatment guidelines/protocols, level of care criteria
- Proficient in the use of computer and multiple software programs.
Demonstrates expertise in medical necessity assessments, utilization management, and compliance with clinical practice guidelines. Holds a current North Carolina Registered Nurse license and possesses extensive nursing experience, ensuring adherence to performance measures and standards.
Highest-signal resume keywords- Medical Necessity Assessment
- Utilization Management
- Clinical Practice Guidelines
- Registered Nurse License
- Nursing Experience
Hard Skills
- Nursing Experience
- Medical Necessity Reviews
- Utilization Reviews
- Diagnostic Treatment Guidelines
- Level of Care Criteria
- North Carolina Registered Nurse License
- Compact License
- Accrediting Body Standards
- Adverse Benefit Determinations
- Due Process Rights
- Co-Morbid Health Conditions
- Computer Proficiency
- Software Programs
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