Primary Responsibilities
The Utilization Management Nurse will determine the medical appropriateness of inpatient and outpatient services by evaluating medical guidelines, benefit determination and compliance with state mandated regulations.
Essential Functions
• Perform concurrent, retroactive and pre-service authorization reviews for inpatient and outpatient services.
• Follow and maintain compliance with CMS requirements, may include after-hours, holiday and weekend coverage.
• Collaborate with staff, physicians, care/service coordinators, and medical directors to coordinate and provide the level of care necessary to meet member’s health need.
Educational/Training Requirements
Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience. Payor Utilization Management: 3 years recommended experience Proficiency with Microsoft Office applications, specifically Word, Excel, and Outlook Proficiency using Milliman Care Guidelines (MCG) and/ or InterQual criteria.
Licensing Requirements
Current unencumbered LVN or RN license in Texas or compact license.
Experience Requirements
2+ years Utilization management experience with a health insurance company (managed care/payer experience required). UM for Medicare Advantage, Managed Medicaid, Dual SNP Lines of Business, on the payer side. 5+ years of acute clinical experience. The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families.Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.