Utilization Management Nurse- RN

Overview

Assess, coordinate, and document member care using clinical expertise in utilization management.

Key Responsibilities

• utilization management
• clinical review
• coverage determination
• case presentation
• care coordination
• discharge planning

Tasks

-Utilizes Utilization management process in compliance with regulatory and company policies and procedures. -Uses clinical tools and information/data review to conduct an evaluation of the members' needs and plan benefits -Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure to render a timely and accurate coverage determination/recommendation. -Presents cases at interdisciplinary care team meetings collaborate with other key stakeholders so that the member can overcome barriers and meet goals and objectives -Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate appropriate healthcare services/benefits. -Identifies members for referral opportunities to integrate into other programs and services. -Works with discharge planners, etc to ensure safe discharge plans for members -Follows members along the continuum of care and communicates with providers and other parties to facilitate care/treatment.

Requirements

• registered nurse
• utilization management
• ms office
• analytical
• problem‑solving
• independent

What You Bring

-3 years working in a managed care setting -Effective computer skills including navigating multiple systems -Confidence working as an independent thinker, using tools to collaborate and connect with teams virtually -Documents in our Utilization Management business application according to defined standards, processes, and workflows -Analytical and problem-solving skills -Ability to work independently -Effective communications, organizational, and interpersonal skills -Registered Nurse with unrestricted licensure -Required Qualifications-Minimum 3-5 years relevant Utilization Management xperience -Proficiency with standard corporate software applications, including Outlook, MS Word, Excel, as well as some proprietary applications

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Benefits

-A competitive salary based on the market -Several supplemental benefits are available, including, but not limited to, Spouse Insurance, Pet Insurance, Critical Illness coverage, ID Protection, etc. -Employer-Paid Life Insurance -Medical, Dental, and Vision -401(K) match up to 4%

About tecsa

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