RN Utilization Management Nurse

RN Utilization Management Nurse

CommuniCare Advantage, a member of CommuniCare Health Services, is currently recruiting an RN Utilization Management Nurse for our Medicare Advantage Plans.

The Utilization Management Nurse uses clinical knowledge, critical thinking, and understanding of criteria sets and Medicare benefits to support the case for treatment, care, and services for our Medicare Advantage Plan members.

WHAT WE OFFER

As a CommuniCare Advantage employee you will enjoy competitive wages and PTO plans. We offer full time employees a menu of benefit options from life and disability plans to medical, dental, and vision coverage from quality benefit carriers. We also offer 401(k) with employer match and Flexible Spending Accounts.

Qualifications & Experience Requirements

• Licensed Registered Nurse (RN) in the (appropriate state) in good standing
• Minimum of 3-5 years’ experience in Utilization Management preferred
• Previous clinical experience in the acute care, post-acute or out-patient setting
• Knowledge of Medicare benefits.
• Experience with InterQual criteria sets preferred.
• Proficiency with a variety of data applications.
• Excellent interpersonal communication, written, and organizational skills required

Knowledge/Skills/Abilities

• Must have integrity and a strong ethical compass.
• Strong planning and organization skills with the ability to work independently.
• Must be flexible, able to work independently, and able to achieve deadlines and deliverables with minimal supervision.
• Must be excited by the opportunity to work within an integrated delivery system.
• Must have strong communication skills and ability to work effectively with people coming from diverse cultural and professional perspectives.

Job Duties & Responsibilities:

As RN Utilization Management Nurse, you will:

• Work in conjunction with the Chief Medical Officer to review all services requiring authorization, recommendations for adverse determinations from internal review or the TPA, clinical information, other mitigating information to support a determination rendered by the CMO.
• Utilize experience with criteria sets, understanding of Medicare benefits, understanding of CHS benefit plan, clinical knowledge, communication skills, and independent critical thinking skills towards applying and interpreting criteria, policies, and most appropriate determination in support of treatment, care or services for members.
• Coordinate and communicate with providers, members, or other parties to facilitate information regarding the determination including authorization or notification of adverse determination to affected parties.
• Ensure determinations are effected timely and in accordance with the CMS requirements and consistent with the departmental policies and processes.
• Uphold the highest ethical standards in facilitating reviews including focus on best possible member care.
• Participate in assigned meetings and committees.
• Participate in the development or revision of processes or procedures.
• Support the administrative tasks related to UM rounds or other meetings as assigned.

Qualified candidates, we look forward to hearing from you!