Utilization Management Nurse

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

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. 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) in Tennessee with no disciplinary action or can have a compact license.
At least 3 years of clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
Comprehensive knowledge of Microsoft Word, Outlook and Excel
Ability to work independently under general instructions and with a team
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
Must be passionate about contributing to an organization focused on continuously improving consumer experiences


Preferred Qualifications


Utilization Review experience
Education: BSN or Bachelor's degree in a related field
Health Plan experience
Previous Medicare/Medicaid Experience a plus
Call center or triage experience
Bilingual is a plus


Additional Information

This is a telephonic work at home based position.

Scheduled Weekly Hours

40

Company info

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