Policy Development Nurse Specialist

6 days ago

Madison, Wisconsin, United States Quartz Health Solutions Full time
Policy Development Nurse

Are you passionate about making a positive impact on member's healthcare by developing medical policies that ensure fair, impartial, and consistent prior authorization decisions?

Key Responsibilities:
  • Collaborate with Medical Directors to research, develop, revise, 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 and incorporate the information into departmental policies as indicated.
  • Research ad-hoc cases identified through Case Review meetings, appeal determinations, and inquiries from providers, Medical Directors and UM staff.
  • Act as MM team 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.
  • Present medical policy and MCG Guideline changes at UM/TAC Meetings and provide ongoing communication regarding changes to the UM team.
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, Microsoft Office.
  • Ability to work autonomously doing clinical research related to medical policy updates and new technology assessment.

Quartz Health Solutions offers an excellent benefit and compensation package, opportunity for career advancement and a professional culture built upon the foundations of Respect, Responsibility, Relationships & Resourcefulness. Quartz is a federal contractor and supports a safe, drug-free workplace. All employment offers are contingent upon successful completion of a pre-employment criminal background check. Quartz values and embraces 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, among other things, or status as a qualified individual with disability.

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