RN Utilization Management Specialist

2 months ago

Park Ridge, United States Managed Care Staffers Full time
Job DescriptionJob Description

Hybrid F/T RN Utilization Management Specialist Needed in Park Ridge, IL

Our client, a growing Medicare Advantage Plans Ins. Co. located in Park Ridge; IL has an immediate need for an experienced partially remote, direct hire full-time IL Licensed RN UM Specialist.

Hours for this position: M-F (8:30am-5:00pm) & one Sat/mo. 9am -1pm.

Job Responsibilities:

  • Performs prospective, initial, concurrent, and retrospective reviews for all requested services to include but not limited to the following: inpatient admissions, concurrent reviews, discharges, (DME), Part B drugs, & outpatient and home health services.
  • Monitors level and quality of care of services being provided and approved.
  • Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
  • Under the supervision of the UM Team Lead and Medical Director, evaluates and provides feedback as needed to treating physicians regarding a member's discharge and home care plans, available covered services including identifying alternative levels of care that may be covered.
  • Monitors the UM system to assure compliance with turnaround time frames.
  • Coordinates an interdisciplinary approach to support continuity of care. Provides UM, transfer coordination, discharge planning, and issuance of all appropriate authorizations
  • Responsible for the early identification and assessment of members for potential inclusion in a comprehensive care coordination program. Refers members for care coordination accordingly.
  • Actively participates in the discussion and notification processes that result from the clinical utilization reviews with members or members’ representatives, facilities, requestors, and service providers.
  • Prepares CMS-compliant notification letters of NON-certified and negotiated days and services within established time frames.
  • Assists in the identification and reporting of Potential Quality of Care concerns.

Job Qualifications:

  • Licensed Registered Nurse
  • Experience in the application of Milliman criteria or other evidence-based medical criteria.
  • 2 – 4 years utilization review and/or managed care experience is preferred.
  • Knowledge of medical problems encountered with Seniors.
  • Working knowledge of Medicare Advantage Plans.
  • Strong computer skills – Microsoft Office Suite & communication and interpersonal skills.

If you or anyone you know is interested, qualified and currently seeking employment please e-mail an updated resume to us for immediate review and consideration.

Company DescriptionWe are employment specialists who have worked in heath care and managed care industry for over a total of 25 years. We staff temp, temp to hire, and direct hire placementsCompany DescriptionWe are employment specialists who have worked in heath care and managed care industry for over a total of 25 years. We staff temp, temp to hire, and direct hire placements

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