Utilization Mgmt Nurse
RemoteTexas, United States or Missouri, United States
Job Summary
Conduct prospective, concurrent, retrospective, and post-service clinical claim certification and authorization reviews to assess medical necessity for inpatient admissions, outpatient services, and out-of-network care. Educate providers on member benefits, coverage, and utilization management processes while facilitating timely transitions of care and discharge planning to appropriate settings. Collaborate with medical directors, pharmacists, and healthcare providers to ensure cost-effective, high-quality care and refer events requiring additional review. Attend weekly rounds to discuss high-cost claims and discharge plans, maintain compliance with Medicare Advantage and URAC standards, and support special projects including new hire training and system implementation. Weekend rotation coverage every six weeks.
Required Qualifications
- Associate's degree in nursing
- Three (3) years' clinical practice experience in a health care setting
- Must hold an active, current, and unrestricted Registered Nurse license from the state of Nebraska or a state in the consortium in which Nebraska participates
- Demonstrated previous experience aligned with the role: Medicare or Commercial Insurance, Medicare Advantage, or Managed Care organizations
- Experience in discharge planning, utilization management, case management, or disease management
- Must be able to work rotating weekend/holiday shifts as needed
- The ability to meet or exceed the attendance and timeliness requirements of their departments
- The ability to work well in a team environment and be capable of building and maintaining positive relationships with other staff, departments, and customers
- Candidates applying to this remote nursing position can live in one of the following states: Florida, Iowa, Kansas, Missouri, Nebraska, North Dakota, and Texas
Desired Qualifications
- Bachelor's degree in healthcare field
- Clinical experience in multiple levels of care
- Knowledge of accreditation standards and regulatory requirements
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