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Utilization Management Nurse
3 months ago
Job Title: Management Nurse
Job Description
- Responsible for meeting all State and Federal regulations as well as company mandates related to claims and preauthorization processing
- Responsible for accurate and timely medical review of claims and preauthorizations
- Responsible for accurate and timely medical review of customer service inquiries about claims and preauthorizations
- Responsible for completion of special projects, including training new hires, provider outreach, project work, peer mentoring, new system implementation, and system testing
- Responsible for determining availability of benefits according to company contracts, endorsements, and medical policy
- Responsible for determining member eligibility prior to medical review
- Responsible for fostering a constructive relationship with all departments
- Responsible for maintaining professional licensure and practicing within the scope of licensure
- Responsible for collaborating and consulting with healthcare providers, members, and internal team of clinical support specialists, nurses, physicians, medical directors, and pharmacists to ensure medically appropriate, high-quality, cost-effective care, promote positive member outcomes, effective use of resources, optimize member benefits, and support business initiatives
Hard Skills
+ RN Compact license from specific states
+ Medical review
+ UM experience
+ Experience with any type of EMR (Guiding Core, InterQual, and MCG preferred)
+ Acute care or post-acute care experience
+ Outpatient care experience
Job Type
This is a contract position with a duration of 6 Month(s).
Work Site
This is a fully remote position.
About Actalent
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
Diversity, Equity & Inclusion
At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:
+ Hiring diverse talent
+ Maintaining an inclusive environment through persistent self-reflection
+ Building a culture of care, engagement, and recognition with clear outcomes
+ Ensuring growth opportunities for our people
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.
