Healthcare Utilization Management Specialist
1 week ago
The Commonwealth of Virginia is seeking a highly skilled Healthcare Utilization Management Specialist to join our team. This role is responsible for promoting and adhering to regulatory compliance, conducting medical necessity reviews, and collaborating with physicians and other healthcare professionals.
Key Responsibilities
* Analyze and evaluate complex medical documentation to ensure adherence to regulatory standards
* Demonstrate competence in interpretation of clinical data and application of utilization management tools
* Collaborate with physicians and care teams to promote effective utilization management practices
* Utilize critical thinking and judgment to determine cases for second-level review and external consultation
* Provide accurate and timely clinical data to insurance companies
* Manage appeals processes with external entities and consultants
Requirements
To be successful in this role, you will need:
* A Bachelor of Science in Nursing from an accredited nursing program
* 2 years of acute care hospital experience
* Licensure to practice as a Registered Nurse in the Commonwealth of Virginia
Preferred Qualifications
* At least 3 years of diverse RN roles in acute, med-surg, and/or adult care
Benefits
This role offers a competitive salary range of $65,000 - $90,000 per year, depending on experience. The Commonwealth of Virginia is an equal opportunity employer and welcomes applications from diverse candidates.
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