Utilization Management Nurse 2 - Front End Review - Northeast Region

Profile

Description

The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

Creating Healthy Communities is good for the Soul. Join Us! The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members.


Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment
Coordinates and communicates with providers, members, or other parties to facilitate appropriate discharge planning including to assist with social determinants and closing gaps
Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas
Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed
Follows established guidelines/procedures


Required Qualifications


Licensed Registered Nurse (RN) with no disciplinary action (New York license is required)
Prior clinical experience preferably in an acute care, post-acute, skilled or rehabilitation clinical setting
Must have good typing skills and proficiency using MS Office Word, Excel and Outlook
Ability to work independently under general instructions and with a team
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required


Preferred Qualifications


Education: BSN or Bachelor's degree in a related field
Active compact state RN license
Health Plan experience
Previous Medicare/Medicaid Experience a plus
Call center or triage experience
Previous experience in utilization management strongly preferred
Previous experience with Milliman (MCG)
Discharge planning and/or home health or rehab


Scheduled Weekly Hours

40

Company info

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