Utilization Management Registered Nurse Jobs

Three years of experience in an acute clinical nursing or medical management setting.

Knowledge of utilization management and case management principles is preferred.

May have an equivalent combination of education and experience to substitute for the experience requirements.

Knowledge of NCQA, Federal and Texas Medicaid Utilization Management (UM) regulations.

Three years of managed care experience is preferred.

Provides appropriate consultation and referral to case management.

Minimum 1 year Utilization Management Experience

Intermediate to advanced computer skills and experience with Microsoft Suite, Word, Excel, Outlook.

Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.

Manager will travel twice a year to South Florida to attend meetings (See Additional Information below)

Minimum 1 year experience with any of the following Team Leadership, Project Leadership, or Subject Matter Expert, SME

Minimum 1-year progressive clinical experience preferably in an acute care clinical setting

Previous utilization management or case management experience preferred.

Minimum 3-5 years of clinical experience and strong working knowledge of disease process, required.

Benefits: Full time benefit package

Knowledge of outside regulatory agencies that interface with the institution.

education and training, the health system has trained nearly 40% of physicians currently practicing

in the state and also provides education and training for other health professionals including nurses,

2+ years of recent acute hospital clinical experience as an RN (recent defined as in the past 10 years).

Experience with all types of Microsoft Office including PowerPoint, Excel, and Word

Must have an active and unrestricted RN license

Must have at least one year of Utilization Review experience to be considered!

100% Remote position; however, must live in the St. Louis metro area!

Ideal candidate will have the following experience:

Experience managing an assignment of labor/delivery and mom/baby admissions to obtain authorizations

Knowledge and use of the CMS 2 Midnight process

Uses clinical and analytical skills to review and interpret diagnostic test results to determine appropriateness of patient's level of care.

Previous experience in utilization management preferred

Working knowledge of regulatory and accreditation standards preferred (URAC, NCQA, DMHC, Case Management Society of America CMSA)

Requires a bachelor's degree or equivalent experience

Requires at least 7 years of prior relevant experience

Strong computer skills related to Windows-based programs and applications

Strong clinical documentation skills, independent problem identification and resolution skills

Experience in utilization review and/or utilization management

Collaborate with UnitedHealthcare Medical Directors on performing utilization management

Follow all Standard Operating Procedures in end-to-end management of cases

Experience in acute, long-term care, acute rehabilitation, or skilled nursing facilities

Apply clinical expertise when discussing case with internal and external Case Managers and Physicians

Identify delays in care or services and manage with MD

This candidate will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.

Weekend/holiday coverage will occasionally be required

Communicates with providers and other parties to facilitate care/treatment

Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function

Identifies members who may benefit from care management programs and facilitates referral

Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization

3+ years of clinical practice experience in an inpatient setting required

2+ years of experience as a Registered Nurse

Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment

Two (2) years acute care nursing experience. One (1) year acute case management or utilization management experience preferred.

Utilization management experience is preferred.

Medical Necessity Criteria (Interqual, MCG) knowledge and experience is preferred.

This is a non-management job that will report to a supervisor, manager, director, or executive.

Other Required Skills and Experience

Currently licensed or eligible to be licensed as a Registered Nurse (RN) by the South Carolina Board of Nursing.

Experience in utilization management or related activities reviewing criteria to ensure appropriateness of care preferred

3-5 years of prior clinical experience preferably in an acute care hospital, skilled or rehabilitation clinical setting

Comprehensive knowledge of Microsoft Word, Outlook and Excel

Excellent communication skills both verbal and written

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Previous Medicare experience a plus

2 or more years of clinical experience preferably in an acute care, skilled or rehabilitation clinical setting

Comprehensive knowledge of Microsoft Word, Outlook and Excel

Previous Medicare/Medicaid Experience a plus

Call center or triage experience

Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment

Previous experience in Case Management, Discharge Planning or Utilization Management

The Utilization Management Nurse 2/Home Health Utilization Management:

Clinical experience in Medicare Home Health (in the last 12 months)

Comprehensive knowledge of Microsoft Word, Outlook and Excel

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Previous Medicare/Medicaid Experience a plus

Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.

Collects and collates data from patient medical records and enters it into a registry form.

Communicates and interacts with physicians and patients to ensure all information is obtained accurately and completely.

Monitors the process of data collection to ensure time frames are met.

Generates reports from the registry and analyzes data to compare organization to similar institutions regarding to key quality indicators.

Measures patient, provider and facility characteristics, cardiac device type and adverse events.

Workstyle: Remote work at home

3-5 years acute care, (Medical Surgical, Heart, Lung or Critical Care), skilled or rehabilitation nursing experience

Previous hospital or health plan utilization management

Comprehensive knowledge of Microsoft Word, Outlook and Excel

Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

Education: BSN or Bachelor's degree in a related field

Excellent organizational and time management skills

2 to 3 years of home health experience and/or utilization management experience

Experience in a managed care setting

Must be passionate about contributing to an organization focused on continuously improving consumer experiences.

Solid analytical skills to understand and interpret data to make recommendations to improve patient care.

Collaboration skills to effectively interact with multiple parties both internal and external.

1+ year in Managed Care/Case Management experience

Working knowledge of coding or utilization management criteria (i.e. MCG, InterQual, CMS)

RN, Registered Nurse, UM, Utilization Management, Inpatient, Acute, Acute RN, Inpatient RN

Working knowledge of Medicare & Commercial Insurance

Knowledge of current standards of patient care

Responsible for all actions/responsibilities as described in company controlled documentation for this position.

Maintain guidelines, federal and state regulations, payer requirements, and best practices related to utilization management.

Educate healthcare professionals and staff on utilization management principles, documentation requirements, and regulatory updates.

Case Management or Utilization Management certification or willingness to obtain within 2 years of hire.

Maintain accurate and thorough documentation of utilization management activities, including reviews, decisions, and interventions.

Identify opportunities for process improvement and participate in quality assurance activities related to utilization management.

Three (3) years of progressively responsible and directly related work experience, preferred.

Previous experience with Utilization Management and/or Case Management is desired.

3-5 years of RN clinical nursing experience is required.

Excellent written and verbal communication skills are required.

Demonstrates excellent interpersonal skills with patients/families, nursing staff, and interdisciplinary team members as demonstrated through written and verbal interactions.

Previous experience performing Utilization Reviews in a RN capacity is recommended.

Previous experience involving high-volume public contact customer service is desired.