UM Clinical Specialist RN
3 weeks ago
This position will allow the successful candidate to work remotely, hybrid or on-site. There is a one weekend quarterly minimum requirement to ensure case compliance. Additional availability expected one major holiday and one minor holiday. The selected candidate must reside in North Carolina.
Responsibilities & Duties
Assesses the medical necessity of services
- Independently conduct medical necessity reviews of service requests submitted by service providers against developed clinical guidelines within contractually mandated turn-around times
- Ensure authorized services address appropriate service needs, intensity of service outcomes, and alternatives for consumers
- Provide a consistent application of medical necessity criteria for physical health services that promotes a holistic review of the member's needs
- Conduct pre-certification, concurrent, and retrospective reviews to ensure compliance with medical policy, member eligibility, benefits, and contracts
- Conduct utilization reviews to monitor adherence to clinical practice guidelines and best practice standards
- Notify members of adverse benefit determinations while preserving members' Due Process rights
- Ensure compliance with performance measures outlined within all accrediting body standards
- Perform other related duties as required by the immediate supervisor or other designated Alliance Health administrators
Compliance
- Comply with utilization management and quality improvement policies and procedures, utilization review laws and regulations, state standards
- Comply with Utilization Management Department focus on timeliness, effectiveness, quantity, quality, and cost of services for eligible enrollees
Coordinate and Implement UM Processes
- Participate in the integration of the department and its functions into the organization's primary mission
- Take part in the Utilization Management Department collaboration to ensure an integrated department with Physical Health and Behavioral Health
Collaborate with other departments
- Monitor for undesirable performance or deviations of practice standards that may have a negative impact on consumers.
- Respond through additional follow-up with consumer and providers, provider technical assistance and/or referral to other departments within the MCO.
- Maintain open, timely communication with staff, providers, community agencies and other stakeholders
Minimum Requirements
Education & Experience
Graduation from a State accredited school of nursing or an Associate's Degree in Nursing from an accredited college/university and five years of nursing experience
OR
Bachelor's degree in Nursing from an accredited college/university and three (3) years of nursing experience
Special Requirement-
Current, active, and unrestricted North Carolina clinical license as a Registered Nurse, or a compact license
Preferred Experience:
Experience in Utilization Management
Knowledge, Skills, & Abilities
- Knowledge of physical health and co-morbid health conditions
- Knowledge of diagnostic treatment guidelines/protocols, level of care criteria
- Proficient in the use of computer and multiple software programs.
- Written and oral communication skills
- Ability to interact with a wide variety of individuals and handle complex and confidential sensitive situations.
- Knowledge of Utilization Management managed care principles and strategies
- Ability to analyze effectiveness of processes and adjust developed processes.
- Knowledge of and experience in acute clinical utilization review
- Knowledge of Authorization/re-authorization Utilization Management standards
- Knowledge of related duties in the delivery of patient care, management of patient care providers, or project management in a healthcare environment
- Ability to lead, delegate and problem solve
- Ability to develop and document workflows
- Ability to assist appeal efforts when medical care is denied by various payor entities in a timely fashion.
- Knowledge of and experience with NCQA
Salary Range
$66,240 to $84,456/Annually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
- Medical, Dental, Vision, Life, Long Term Disability
- Generous retirement savings plan
- Flexible work schedules including hybrid/remote options
- Paid time off including vacation, sick leave, holiday, management leave
- Dress flexibility
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