This position is for a premier client.
Department:
Medical Management
Job Title:
RN Utilization Management
Reports to:
Director, Medical Risk Management
Position Overview: This job description provides an overview of the role's general nature and responsibilities. It does not encompass a comprehensive list of all duties, responsibilities, and skills required for individuals in this classification. This position is onsite, located in Cincinnati.
As a Utilization Review nurse, you will be responsible for overseeing a designated group of employees/employers. This role entails daily Utilization Management (UM) reviews including pre determination, concurrent and retrospective requests.
Key Responsibilities:
- Conduct daily reviews of UM pre-certifications, continued stays, and retro review requests using evidence-based criteria. Promptly notify providers and members following ERISA guidelines.
- Maintain professional, timely, and thorough responses to internal and external customers.
- Update the plan of care for high-cost members during pre-certification requests, gather diagnostic study results, and determine specialty drug costs.
- Collaborate with Account Management, Stop Loss, Sales, and Operations teams to fulfill the needs of employees/employers.
- Serve as a backup for Case Management RN when required.
- Perform additional assigned duties as needed.
Essential Qualifications:
- Minimum of 2 years of UM experience. Certification in Utilization Management is preferred.
- Valid RN licensure in either KY, OH, or IN.
- Clinical background with diverse provider-side experience and/or payer-side experience in UM.
- Strong ability to establish rapport and build relationships over the phone.
- Proficient record-keeping and reporting skills.
- Capable of managing the medical management book of business for assigned employers.
- Positive attitude with a commitment to excellent customer service.
- Thrives in an environment of continuous improvement and adaptability.
- Effective team contributor while also fostering individual development.
Key Fundamentals: 1. Take Care of Our Clients; 2. Deliver Results; 3. Be a Great Teammate; 4. Be Positive and “Bring It”; 5. Listen Generously; 6. Be a Lifelong Learner; 7. Align with Change
StrengthsFinder: Achiever-E; Maximizer-I; Analytical-S; Communication-I; Positivity-R; Adaptability-R; Arranger-E; Learner-S; Developer-R; Restorative-E
