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.
Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action.
3-5 years of prior clinical experience preferably in an acute care 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
Education: BSN or Bachelor's degree in a related field
Health Plan experience
Previous Medicare/Medicaid Experience a plus
Previous experience in utilization management
Experience with Milliman (MCG) a plus
Scheduled Weekly Hours