Utilization Management Nurse
On-siteChapel Hill, North Carolina, United States
Job Summary
Conduct clinical utilization reviews using evidence-based guidelines, policies, and nationally recognized clinical criteria while performing medical necessity and benefit review requests. Identify potential Third-Party Liability and Coordination of Benefit cases, triage and prioritize assigned duties to meet required turnaround times, and collaborate with healthcare partners to ensure timely service reviews. Provide referrals to Case management, Disease Management, Appeals, and Quality Departments as needed. Prepare and present cases to the Medical Director for oversight and necessity determinations, then communicate determinations to providers and members in compliance with regulatory and accreditation standards. Maintain active and unrestricted RN licensure, work independently in a high-pace remote environment, and apply proficiency in MCG and CMS criteria sets.
Required Qualifications
- Current Registered Nurse (RN) with state licensure
- Must retain active and unrestricted licensure throughout employment
- Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
- Must be able to work independently
- Detail oriented
- Strong organizational and time management skills
- Adaptive to a high pace and changing environment
- Flexibility in assignment
- Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review
- Proficient in MCG and CMS criteria sets
- 2+ years' experience in a UM team within managed care setting
Desired Qualifications
- Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases
- Working knowledge of URAC and NCQA
- 3+ years' experience in clinical nurse setting
- TPA Experience
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