What are the responsibilities and job description for the Utilization Management Nurse position at US Tech Solutions?
Job Description :
Remote once training is complete. M-F 8 : 30am – 5pm.
Experience : Hospital experience, UM experience
Description : office work, at a desk 8 hours per day, reading clinical and processing request.
Must be able to understand computers, all work is electronic.
Soft Skills : Strong communication skills, they will talk to providers over phone. Strong reading comprehension as they will read and interpret medical policies.
Responsibilities :
Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions. Utilizes clinical proficiency, claims knowledge / analysis, and comprehensive knowledge of healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost effective outcomes. Performs medical or behavioral review / authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.). Participates in data collection / input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal).
Provides discharge planning and assesses service needs in cooperation with providers and facilities. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. Collaborates with Care Management and other areas to ensure proper care management processes are executed within a timely manner. Manages assigned members and authorizations through appropriate communication. Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members. Participates in direct intervention / patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. May identify, initiate, and participate in on-site reviews. Promotes enrollment in care management programs and / or health and disease management programs. Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and / or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.
Experience :
3 years clinical experience.
Skills :
Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Required Software and Tools : Microsoft Office. Preferred Skills and Abilities : Working knowledge of spreadsheet, database software. Knowledge of contract language and application. Thorough knowledge / understanding of claims / coding analysis / requirements / processes.
Preferred Software and Other Tools : Working knowledge of Microsoft Excel, Access or other spreadsheet / database software. Work Environment : Typical office environment.
Education :
Associate Degree - Associate Degree - Nursing, or Graduate of Accredited School of Nursing.
Required License / Certificate : Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
About US Tech Solutions :
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit .
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity,
national origin, disability, or status as a protected veteran.
recruiter details : Vivek Kumar
vivek.kumar@ustechsolutionsinc.com
Internal ID : 25-29975
