Utilization Management Nurse

SIHO Insurance Services; Columbus (IN); Vor Ort; USD 70.000 - 90.000; Vollzeit

Zusammenfassung

SIHO Insurance Services seeks an experienced Utilization Management Nurse in Columbus, IN. This full-time, exempt RN role focuses on coordinating care, ensuring medical necessity, and aligning services with plan guidelines across episodes of care.

You will perform pre-service, concurrent, and post-service reviews, interact with members and providers, document thoroughly in the standard system, and collaborate with the Medical Director to ensure timely, compliant decisions.

Qualifikationen

• RN with current, unrestricted license in primary state of employment.
• UM or Health Plan experience preferred.
• Fast-paced environment with focus on efficiency and quality.
• Strong self-directed organization and prioritization.
• Sound clinical background with clinical field experience.
• Excellent verbal and written communication skills.
• Microsoft Office Experience: Outlook, Word, Excel.

Aufgaben

• Perform pre-service, concurrent, and post-service review for medical necessity using enrollee records and guidelines.
• Interact with members, providers, and care teams to complete reviews efficiently.
• Consult with the SIHO Medical Director to ensure timely medical necessity decisions.
• Document reviews in the established system ensuring data integrity and reporting metrics.
• Complete case review and elevation to determinations within contractual and CMS turnaround times.
• Assist in resolving problems and provide guidance to team members.
• Interpret and abide by organizational policies and ensure proper policy application.
• Act as a clinical resource for medical management, utilization review, and medical necessity.
• Support department strategies focused on quality improvement.
• Identify and report potential Quality of Care concerns and Fraud, Waste and Abuse incidents.
• Work as part of an interdisciplinary team for all lines of business.

Kenntnisse

RN licensure

UM/Health Plan experience

Fast-paced environment

Time management

Clinical background

Verbal & written communication

MS Office (Outlook, Word, Excel)

Tools

Outlook

Word

Excel

Jobbeschreibung

Job Title: Utilization Management Nurse

Reports To: Manager of Utilization Management

Employment Type: Full-Time, Exempt

Brief Description of Duties

This position is reserved for a licensed Registered Nurse who will perform the Utilization Management (UM) services for SIHO (and affiliated business lines’) members. This individual’s primary role is to ensure that health care services are administered with quality, cost effectiveness, and compliance to plan guidelines are maintained. By performing review of services prospectively, retrospectively, and throughout the episode of care, the UM nurse will make coverage determinations influencing how services are allocated to SIHO’s various member populations. A candidate’s ability to perform quality reviews within strict efficiency standards is required for this position. Key responsibilities are as follows:

• Pre-service, concurrent, and post-service review of necessity of health care services utilizing enrollee medical records and established guidelines set by SIHO and/or state and federal (CMS) guidelines
• Interaction with the member, health care provider, and/or other care team members to complete reviews in most time-efficient manner
• Interaction with the SIHO Medical Director as needed to ensure proper medical necessity decisions are made in a timely manner
• Appropriate documentation of the entire review process utilizing the established documentation system and desk procedures to guarantee accurate reporting metrics and data integrity
• Complete case review and elevation to determinations that are rendered within the contractual and regulatory turnaround times established by SIHO and CMS
• Assist to resolve problems and provide guidance to members of the team and cohorts
• Interpret and abide by organizational policies and procedures; review work regularly to ensure that policies and guidelines are appropriately applied
• Act as a clinical resource to the department and other organization members for services pertaining to medical management, utilization review, and medical necessity
• Act and perform within the scope of professional nursing practice; is responsible in supporting and participating in department strategies and efforts focused on quality improvement
• Responsible for the early identification and assessment of members for inclusion in disease management or care management programs
• Assist in the identification and reporting of Potential Quality of Care concerns and Fraud, Waste and Abuse incidents
• Work as an interdisciplinary team member within Medical Management for all lines of business and commercial group plans

Minimum Skills Requirement

• Registered Nurse with current, unrestricted license in primary state of employment (position may require additional licensing in other states as necessary)Previous UM or Health Plan experience highly preferred
• Desire to work in a fast-paced environment with focus on efficiency while maintaining quality
• Self-directed organization and prioritization skills, and independent time management skills required
• Sound clinical background with experience in the clinical field
• Excellent verbal and written communication skills
• Microsoft Office Experience: Outlook, Word, Excel