Clinical Policy Nurse

2 weeks ago

Madison, Wisconsin, United States Quartz Full time
Position Overview

Are you enthusiastic about exploring innovative medical procedures and cutting-edge technologies? Do you have a strong commitment to enhancing healthcare outcomes for members by formulating medical policies that guarantee equitable, unbiased, and consistent prior authorization decisions?

If this resonates with you, consider the role of a Policy Development Nurse within our Utilization Management division. This position entails conducting assessments and research on technologies to create, maintain, revise, and implement national evidence-based criteria and internally developed medical policies. Additionally, the role ensures that our medical management team is well-equipped to utilize the established medical criteria for the prior authorization of high-quality medical benefit services in a consistent, timely, and fair manner.

Employee Benefits
  • Enjoy the autonomy of independent work while benefiting from collaborative team efforts.
  • Full-time remote, telecommuting, work from home options available, if preferred.
  • Competitive starting salary range, based on skills and relevant experience: $71,000 - $88,800, along with a comprehensive total rewards package.
Key Responsibilities
  • Collaborate with the Medical Director for Policy Development and other Medical Directors to research, create, revise, and implement tailored medical policies and MCG Guidelines.
  • Participate in Case Review meetings to oversee utilization, relevance, and consistency in the application of review criteria.
    • Identify and investigate opportunities for new technology assessments, presenting findings to medical director staff and integrating this information into departmental policies as necessary.
    • Conduct research on ad-hoc cases identified through Case Review meetings, appeal determinations, and inquiries from providers, Medical Directors, and UM staff.
  • Serve as a resource for the medical management team regarding inquiries related to medical policy and MCG CareWebQI Guidelines.
  • Engage with provider specialists to gather their insights on medical policies and communicate any policy-related changes.
  • Present updates on medical policy and MCG Guideline changes at UM/TAC Meetings, ensuring ongoing communication regarding changes to the UM team.
Qualifications
  • Bachelor's or associate degree in Nursing or a related field.
  • A minimum of 3 years of RN utilization management experience in clinical and/or inpatient settings.
  • Preferred experience in insurance/managed care, clinical research, and policy development.
  • Familiarity with managed care principles related to per diems, DRGs, CPT/HCPCS, and ICD-10 coding.
  • Understanding of the utilization management process.
  • Experience with NCQA and CMS guidelines.
  • Proficient computer skills, including knowledge of health system databases, evidence-based decision support software, and Microsoft Office.
  • Ability to work independently on clinical research related to medical policy updates and new technology assessments.
This full-time position may offer remote work options. The company will provide necessary hardware and equipment, but candidates must have access to high-speed, non-satellite Internet to effectively work from home.

Quartz is committed to providing an excellent benefits and compensation package, opportunities for career growth, and a professional culture grounded in Respect, Responsibility, Relationships, and Resourcefulness. As a federal contractor, Quartz promotes a safe, drug-free workplace. All employment offers are contingent upon successful completion of a pre-employment criminal background check.

Quartz values diversity and is proud to be an Equal Employment Opportunity, Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity or expression, sexual orientation, age, status as a protected veteran, or status as a qualified individual with a disability.

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