Utilization Management Nurse
5 giorni fa
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions.
We are currently seeking a skilled Utilization Management Nurse to join our team
Job Description:The ideal candidate will have 4 years of recent clinical experience in a defined specialty area, such as oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, or general medicine/surgery. Alternatively, the candidate may have 4 years of utilization review/case management/clinical/or combination experience, with at least 2 years of clinical experience.
Responsibilities:
- Review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provide health management program interventions.
- Utilize clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness.
- Perform medical or behavioral review/authorization process, ensuring coverage for appropriate services within benefit and medical necessity guidelines.
- Identify and make referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.). Participate in data collection/input into the system for clinical information flow and proper claims adjudication.
Required Skills and Qualifications:
- Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
- Associate Degree - Nursing, or Graduate of Accredited School of Nursing.
Benefits:
- Fast-paced, interactive team works with multiple applications to process authorization and appeals requests using Medicare criteria.
- Able to work independently, prioritize effectively, and make sound decisions.
- Demonstrated customer service, organizational, and presentation skills.
Others:
- Ability to persuade, negotiate, or influence others.
- Analytical or critical thinking skills.
- Ability to handle confidential or sensitive information with discretion.
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