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Policy Development Nurse Specialist

1 month ago

Madison, Wisconsin, United States Quartz Full time
Job Summary

We are seeking a highly skilled Policy Development Nurse to join our Utilization Management team at Quartz. As a key member of our team, you will be responsible for researching and developing medical policies that ensure fair, impartial, and consistent prior authorization decisions.

Key Responsibilities
  • Collaborate with Medical Directors to research, develop, and implement custom medical policies and MCG Guidelines.
  • Attend Case Review meetings to monitor utilization, relevance, and consistency in use of review criteria.
  • Identify and research opportunities for new technology assessment and present this information to medical director staff.
  • Act as a resource for questions related to medical policy and MCG CareWebQI Guidelines.
  • Provide outreach to provider specialists to obtain their input on medical policies and communicate policy-related changes.
Requirements
  • Bachelor's or associate degree in Nursing or related field.
  • 3+ years of RN utilization management experience in a clinical and/or inpatient setting.
  • Insurance/managed care, clinical research, and policy development experience preferred.
  • Knowledge of managed care as it relates to per diems, DRG's CPT/HCPCS and ICD-10 coding.
  • Knowledgeable in the utilization management process.
  • NCQA and CMS guidelines experience.
  • Strong computer skills, including familiarity with health system databases, evidence-based decision support software, and Microsoft Office.
What We Offer
  • Full-time virtual, telecommuting, work-from-home environment available.
  • Ideal starting pay range, based on skills and applicable experience: $71,000 - $88,800 plus a robust total reward package.
  • Opportunity for career advancement and a professional culture built upon the foundations of Respect, Responsibility, Relationships & Resourcefulness.