Registered Nurse (RN), Utilization Review - Remote

Employment Type: Full time Shift: Description: Why MediGold? MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more. We know that exceptional patient care starts with taking care of our colleagues, so we invest in great people and all that we ask in return is that you come to work ready to make a difference and do the right thing. What we offer: Competitive compensation and benefits packages including medical, dental, and vision coverage Retirement savings account with employer match starting on day one Generous paid time off programs Employee recognition incentive program Tuition/professional development reimbursement Relocation assistance (geographic restrictions apply) Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing Why Columbus? The nation's 14th largest city, Columbus, Ohio is one of the fastest growing major metropolitan areas in the Midwest – ranked #1 for population growth, #1 for job growth, #1 for wage growth, and #1 real estate market. And with a vibrant blend of professional sports, world-class attractions, creative cuisines, and a flourishing music and arts scene, you'll never be found wanting for entertainment and experiences to call your own in Columbus. Learn more at www.experiencecolumbus.com! About the job: The Utilization Review Nurse ensures that authorization requests and provider or member inquiries are handled appropriately within established timeframes, and established guidelines and protocols are utilized for clinical decision-making. In collaboration with providers and the Medical Director, the Utilization Review Nurse ensures medical appropriateness and effective utilization of health care resources. Responsibilities Performs clinical review and provider/member notification in a timely manner. Partners and collaborates with provider partners on Utilization Review processes. Provides exceptional customer service to providers and members. Collaborates with management to promote improvements in work processes within department and organization. Responsible/accountable for professional development and maintaining licensure. Refers quality issues and poor utilization of services to the appropriate sources. Consults with Medical Directors as needed and as outlines in policies and procedures Coordinates activities with other medical management departments as needed, including making referrals to Case Management and Behavioral Health Attends and actively participates in staff meetings, participates in committees as requested. Provides orientation of other Utilization Review Nurses as requested. All other duties as assigned. Requirements Graduate from a school of nursing. Baccalaureate degree in nursing preferred. Current license to practice as registered nurse in the State of Ohio. CCM, ACM or CPHM preferred. Minimum of 3-5 years nursing experience and knowledge of the utilization review process. Prior managed care and/or Medicare experience is preferred. Strong organization skills, self-directed, flexible, able to adapt to rapidly changing regulatory requirements. Possesses excellent clinical assessment and analytical skills. Computer competency Possesses effective interpersonal skills, can work across departmental boundaries and facilitates problem resolution. Knowledge of the functional operations of utilization management, care coordination and transitions of care. Proven ability to work independently, with attention to detail and accuracy. Discovering opportunities, support and excellence – all while making a real difference in patients’ lives – begins at Mount Carmel. Find a new beginning and advance your career with us. Mount Carmel and all its affiliates are proud to be equal opportunity employers. We do not discriminate on the basis of race, gender, religion, sexual orientation or physical ability. Our Commitment to Diversity and Inclusion Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law. Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs. For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.