registered nurse Remote
Job description
REPORTS TO: Manager, Care Management Services
LOCATION: Missoula or WAH
FSLA STATUS: Exempt
OP UTILIZATION MANAGEMENT RN
POSITION RESPONSIBILITIES:
The Utilization Review RN is responsible for promoting the quality and cost-effectiveness of medical service and admission reviews by applying clinical judgement in accordance with medical policies and national guidelines to determine authorization/certification of said service/admission. The UM RN ensures that all reviews are completed in a timely fashion to meet contractual requirements. This position may also include participating in team functions such as committees, QA team evaluations, and preceptorships.
The incumbent is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and be respectful and courteous in the conduct of this position. Oncology experience preferred.
ESSENTIAL JOB FUNCTIONS:
Essential job functions include the following. Other functions may be assigned as business conditions change.
Conducts reviews, facilitates planning referrals, and screens for and initiates referrals for Case Management.
Identifies and refers cases NOT meeting criteria and coordinates appeals and denials with Medical Directors.
Maintains an intimate working knowledge of clinical guidelines (ASAM, MCG, URAC), clinical decisions support tools, Cigna medical policies and effective usage of care management documentation systems.
Provides services within the scope of practice defined by current education, certification or licensure, community and published standards.
Assist Senior Management with special requests that pertain to team.
Responsible for maintaining confidentiality standards, as mandated by HIPAA
Organizes personal workload and contributes time and effort to the team workload by:
Ensuring that phone calls are returned by the next business day.
Completing all reviews and reporting in a timely manner.
Maintaining a thorough knowledge of and compliance with policies, procedures, and Quality Assurance requirements.
Attending and/or participating in the majority of staff/team meetings.
Identifying, evaluating, and providing feedback on departmental workflows to increase efficiency.
Participates in orientation and training of new employees.
Perform other duties and job functions as assigned.
NON-ESSENTIAL JOB FUNCTIONS:
Preparation of forms, faxing, copying.
Organization of files and reference materials.
Ability to operate typical office equipment and working knowledge of basic office practices.
PHYSICAL WORKING CONDITIONS:
Physical requirements are representative of those that must be met to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
JOB SPECIFICATIONS:
To perform this position successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
Minimum Experience: Two years experience in medical/surgical, rehabilitation, psychiatric, or emergency services, and/or certification review experience; comparable outpatient experience.
Other Experience:
Must be able to operate a personal computer, copier, fax machine, and telephone.
Must be able to access, research and extract information from printed resources, computer terminals, medical records, and telephone interviews on a daily basis.
Must have strong organizational skills, the ability to follow directions, interpret instructions, and solve practical problems.
Must have excellent communications skills (oral and written) and be customer service oriented.
Must be able to function independently, effectively, and cooperatively with little supervision, meet assignment deadlines, work with a variety of tasks simultaneously, do detailed work accurately, and follow through to completion.
Must be knowledgeable about managed care, insurance reimbursement industries, and benefit design and use in treatment planning process.
The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel as classified. By signing this statement, the employee understands the scope of their licensure and will practice within the scope of that licensure. If the status of the licensure/certification changes, the employee will notify the department supervisor of the change immediately. The employee understands that failure to maintain current licensure and/or to practice within the scope of that licensure, as well as failure to report any changes in license status, will result in disciplinary action, up to and including termination.
- Allegiance Benefit Plan Management, INC is an Equal Opportunity Employer. Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you require reasonable accommodation in completing the online application process, please email: [email protected] for support.
