Care Management & Utilization Review Nurse

Peak Health; Core (WV); In loco; USD 70.000 - 100.000; Tempo pieno

Descrizione del lavoro

PHH Peak Health Holdings is seeking a registered nurse with 3+ years of healthcare clinical experience to support care management and utilization management for Medicare/Medicaid populations. The role builds and implements review processes, collaborates with Medical Directors, and educates stakeholders to improve member outcomes and service quality.

Clinical proficiency in InterQual/Milliman Guidelines and knowledge of NCQA regulations are essential.

Competenze

• Current Registered Nurse license required in the state of service or multi-state license via eNLC.

Mansioni

• Assist in building and implementing care management review processes (Prior Authorization, Predetermination, Concurrent/Retrospective Reviews).
• Ensure interventions maximize member health outcomes and align with guidelines.
• Collaborate with Medical Directors to improve member and provider network services.
• Educate internal/external stakeholders to improve processes and relationships.
• Collaborate with the medical management team to identify opportunities for coaching and case management.

Conoscenze

InterQual/Milliman Guidelines

Regulatory knowledge

Communication skills

Problem solving

Attention to detail

Microsoft Office

Formazione

BSN

ASN

Descrizione del lavoro

PHH Peak Health Holdings is seeking a registered nurse with 3+ years of healthcare clinical experience to support care management and utilization management for Medicare/Medicaid populations. The role builds and implements review processes, collaborates with Medical Directors, and educates stakeholders to improve member outcomes and service quality.

Clinical proficiency in InterQual/Milliman Guidelines and knowledge of NCQA regulations are essential.