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Nurse for Utilization Management
2 months ago
Position Overview:
We are seeking a dedicated Utilization Management Nurse to contribute to a prominent health plan. This role offers a competitive hourly wage and operates on a standard weekday schedule.
Key Responsibilities:
As a Utilization Management Nurse, you will be responsible for:
- Ensuring compliance with all relevant State and Federal regulations, along with company policies regarding claims and preauthorization processes.
- Conducting precise and timely medical evaluations of claims and preauthorizations.
- Addressing customer service inquiries related to claims and preauthorizations with accuracy and efficiency.
- Completing special projects, which may include training new employees, engaging with providers, participating in project work, mentoring peers, and assisting with system implementations and testing.
- Assessing the availability of benefits in accordance with company contracts, endorsements, and medical policies.
- Verifying member eligibility prior to conducting medical reviews.
- Fostering collaborative relationships across various departments.
- Maintaining professional licensure and adhering to the scope of practice.
- Collaborating with healthcare providers, members, and a multidisciplinary internal team to ensure high-quality, cost-effective care that promotes positive outcomes and optimizes resource utilization.
Qualifications:
To be considered for this role, candidates should possess:
- A valid RN Compact license from designated states.
- Experience in medical review and utilization management.
- Familiarity with electronic medical records (EMR), with preference for systems such as Guiding Core, InterQual, and MCG.
- Experience in acute care or post-acute care settings.
- Background in outpatient care.
Work Environment:
This position is fully remote.
About Actalent:
Actalent is a global leader in engineering and scientific services, providing talent solutions to help companies achieve their engineering and science goals through access to specialized expertise.
Diversity, Equity & Inclusion:
At Actalent, we believe that diversity and inclusion are essential to the success of our workforce. We are committed to:
- Hiring a diverse range of talent.
- Creating an inclusive environment through ongoing self-reflection.
- Building a culture of care, engagement, and recognition.
- Providing growth opportunities for all employees.
Actalent is an equal opportunity employer and welcomes applications from all individuals, regardless of race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information, or any characteristic protected by law.
