Utilization Review Nurse

To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Responsible for working in collaboration with the Medical Director on driving the decrease in care variance, to ensure timely discharges, and to refer members to other plan resources to meet their care conditions. Reports to the Health Plan Manager of Utilization Management. This position will be an integral member of the health plan’s medical management team. This position is a collaborative member of the Medical Management team. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC). Three (3) years of healthcare clinical experience. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); Medical Management for Medicare and/or Medicaid populations. Assists with the build and implements care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards. Assists with the build and implements all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies. Ensures that interventions are collaborative and focus on maximizing the member’s health care outcomes. Understands the Peer-to-Peer Review process and works with the Medical Directors to continuously improve member and Provider Network services for this process. Educates internal and external stakeholders and partners to continuously improve processes and build network relationships. Works collaboratively with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions. Understands the data that is collected within the position, and work with other team members on improving outcomes. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Standard office environment. Working Knowledge of InterQual and/or Milliman Care Guidelines. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning. Problem solving capabilities to drive improved efficiencies and customer satisfaction. Proficiency with Microsoft Office. This role may require occasional weekend and holiday work. 40 Shift: PHH Peak Health Holdings Cost Center: 2403 PHH Medical Management