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Utilization Management Nurse
1 month ago
Position Overview:
The Utilization Management (UM) Nurse assesses healthcare services to ensure optimal outcomes, cost-effectiveness, and compliance with state and federal regulations. This role involves analyzing clinical service requests, conducting prior authorization reviews, and collaborating with multidisciplinary teams to promote the Care Model.
Key Responsibilities:
Service Assessment & Compliance:
Evaluate healthcare services to guarantee optimal patient outcomes and adherence to all regulatory standards.Clinical Review & Authorization:
- Analyze clinical service requests against evidence-based guidelines (e.g., MCG).
- Conduct prior authorization reviews, determining financial responsibility for both Healthcare and its members.
- Process requests efficiently within required timelines, completing 15–20 authorizations daily.
Benefit & Eligibility Identification:
Confirm eligibility and benefits for requested treatments or procedures.Medical Director Referrals:
Refer complex prior authorization requests to Medical Directors as needed.Information Management:
Request additional information from members or providers in a consistent, efficient manner.Team Collaboration:
Work closely with multidisciplinary teams to implement the Molina Care Model.
Make appropriate referrals to other clinical programs when necessary.Policy Adherence:
Follow all UM policies and procedures consistently.
Requirements:
Education & Licensure:
- Active RN or LPN license.
- Minimum 1 year of Utilization Management experience in a health plan setting.
Technical Skills:
- Proficient in utilizing systems like QNXT/UMK2 (preferred).
- Experience with MCG guidelines (preferred).
Work Environment:
- Ability to work remotely in a high-paced, high-demand environment.
- Complete 15–20 authorizations per day, including reviews of prior authorization, inpatient, and skilled nursing requests.
Options for schedule:
Schedule A:
- Sunday: Off
- Monday: Off
- Tuesday: 9:00 AM – 6:30 PM
- Wednesday: 9:00 AM – 6:30 PM
- Thursday: 9:00 AM – 6:30 PM
- Friday: 9:00 AM – 6:30 PM
- Saturday: 10:00 AM – 2:00 PM
Total Hours: 40 per week
Schedule B:
- Sunday: 10:00 AM – 2:00 PM
- Monday: 9:00 AM – 6:30 PM
- Tuesday: 9:00 AM – 6:30 PM
- Wednesday: 9:00 AM – 6:30 PM
- Thursday: 9:00 AM – 6:30 PM
- Friday: Off
- Saturday: Off
Total Hours: 40 per week
Schedule C:
Week 1:
- Sunday: Off
- Monday: 8:30 AM – 5:00 PM
- Tuesday: 8:30 AM – 5:00 PM
- Wednesday: Off
- Thursday: 8:30 AM – 5:00 PM
- Friday: 8:30 AM – 5:00 PM
- Saturday: 10:00 AM – 6:30 PM
Week 2:
- Sunday: 10:00 AM – 6:30 PM
- Monday: 8:30 AM – 5:00 PM
- Tuesday: Off
- Wednesday: 8:30 AM – 5:00 PM
- Thursday: 8:30 AM – 5:00 PM
- Friday: 8:30 AM – 5:00 PM
- Saturday: Off
Total Hours: 40 per week
Company DescriptionSince our founding in 2005, MedNational has grown into a full-service Healthcare Human Capital Solutions Organization. We are proud to deliver our traditional permanent placement and contract service opportunities.MedNational professionals experience career opportunities in the following niche areas:
• Hospitals
• Physicians’ offices
• Nursing care facilities
• Home healthcare services
• Government agencies
• Educational services
• Support services
• Schools
• Community centers
• Urgent care centers
• Offices
Today, we conduct business in all corners of North America, and continue to be laser focused on our mission. We deliver our clients with career oriented and quality-focused health care professionals while enriching the lives of these professionals during their period of transition to a new challenge and opportunity.Company DescriptionSince our founding in 2005, MedNational has grown into a full-service Healthcare Human Capital Solutions Organization. We are proud to deliver our traditional permanent placement and contract service opportunities.\r
\r
MedNational professionals experience career opportunities in the following niche areas:\r
• Hospitals\r
• Physicians’ offices\r
• Nursing care facilities\r
• Home healthcare services\r
• Government agencies\r
• Educational services\r
• Support services\r
• Schools\r
• Community centers\r
• Urgent care centers\r
• Offices\r
\r
Today, we conduct business in all corners of North America, and continue to be laser focused on our mission. We deliver our clients with career oriented and quality-focused health care professionals while enriching the lives of these professionals during their period of transition to a new challenge and opportunity.
