Utilization Management Nurse

MyTruAdvantage; Columbus (IN); On-site; USD 65,000 - 90,000; Full time

Job summary

MyTruAdvantage is seeking an Utilization Management Nurse in Columbus, IN. This full-time, exempt role requires a licensed RN to perform prospective, concurrent, and retrospective reviews to ensure appropriate, evidence-based utilization of services.

You will interact with members, providers, and the care team to reach timely medical-necessity determinations while maintaining policy compliance and accurate documentation. Strong MS Office skills are essential, and prior UM experience is preferred.

Qualifications

• Licensed Registered Nurse with a current, unrestricted license.
• Prior utilization management or health-plan experience preferred.
• Proficient in Microsoft Office (Outlook, Word, Excel).

Responsibilities

• Pre-service, concurrent, and post-service review of medical necessity.
• Review enrollee records and apply guidelines from SIHO and CMS.
• Document reviews accurately in the designated system.
• Collaborate with care team to ensure timely medical necessity decisions.
• Support quality improvement initiatives and data reporting.

Skills

Registered Nurse

UM experience

Time management

Communication skills

MS Office

Education

RN license

Tools

Outlook

Word

Excel

Job description

Utilization Management Nurse# Utilization Management NurseHot Job417 Washington Street - Columbus, IN 47201## OverviewCategoryNurse## Description**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## Qualifications**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