Judge Healthcare is looking for a Utilization Management Nurse with a TN or Compact License for a REMOTE position!
Please send your resume to Kevin Koren kkoren@judge.com 610-784-8284
MUST have: 5+ years of clinical exp+ UM RN + Pain management experience
Job Details:
- Title: Utilization Management RN
- Location: Remote in the US
- Type of engagement: Ongoing contract (6+ months)
- Hours: Reg business hours (Occasional weekend work may be required)
Responsibilities:
- Performs comprehensive pre-existing reviews and makes clinical determinations of pre-existing or not pre-existing status based on medical judgment and contractual eligibility of the services provided.
- Performs these reviews in a timely manner meeting departmental and corporate turnaround requirements.
- Performs thorough research and provides complete documentation for rationale to support both determinations of pre-existing and not pre-existing, as well as specific written instructions regarding additional information necessary to complete the review.
- Performs review of rider-related diagnoses, potential misrepresentation referrals, provider and member appeals, and rider-related drug appeals.
- Seeks the advice of the Utilization Management Medical Director as appropriate.
- Proficient in interpreting benefits, contract language specifically symptom-driven, treatment-driven, look-back periods, and rider information, and medical policy language.
- Maintains and/or assists with tracking reporting, and audits to monitor productivity, turnaround times, and quality.
- Interacts with Claims, Customer Service, Compliance, Configuration, and other departments as necessary to ensure all guidelines are followed.
- Performs or participates in special studies or projects as directed by department management.
- Promotes positive public relations with providers, member, employees, and the community at large.
- Assists or performs other duties as assigned.
Qualifications
- RN license in TN or compact license
- 5 years – Clinical experience required
- Utilization Management experience
- Pain Management experience
- CASE MANAGER experience is a plus
- Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
- Working knowledge of URAC, NCQA and CMS accreditations
- Must be able to work in an independent and creative manner.
- Excellent oral and written communication skills
- Strong interpersonal and organizational skills
- Ability to manage multiple projects and priorities
- Adaptive to a high pace and changing environment
- Customer service oriented
- Superior interpersonal, client relations and problem-solving skills
- Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria