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.
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.
2+ clinical experience preferably in case management, utilization review, acute care, skilled nursing or rehabilitation clinical setting
Licensed Registered Nurse (RN) in Tennessee with no disciplinary action.
Comprehensive knowledge of Microsoft Word, Outlook and Excel
Ability to work independently under general instructions and with a team
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
Candidate should live within a reasonable commuting distance to Knoxville TN
Scheduled Weekly Hours