Utilization Management Nurse

Health One Alliance, LLC; Dalton (GA); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

401K (4% Match, Immediate Vesting)

Medical Insurance

Paid Time Off

Life & AD&D Insurance

Job summary

Health One Alliance, LLC is seeking a Utilization Management Nurse to perform clinical reviews and ensure quality patient care. The role involves coordinating care referrals and reviewing claims while adhering to HIPAA regulations.

The candidate should have significant clinical experience and a current RN license. Benefits include competitive salary, various insurance options, and a matching 401K plan.

Qualifications

• 3 years of clinical experience preferred.
• 1-2 years of utilization review preferred.
• Adaptive to high pace and changing environment.

Responsibilities

• Perform comprehensive clinical reviews of requested services.
• Initiate referrals to ensure appropriate coordination of care.
• Assist non-clinical staff in administrative reviews.

Skills

Clinical experience

Utilization Review

Proficiency in Microsoft Office

Customer service orientation

Interpreting medical policy

Education

Current, active Compact State license in Nursing (RN)

Job description

Job Purpose

The Utilization Management Nurse performs comprehensive clinical reviews of requested services utilizing clinical criteria, received through various mechanisms.

Essential Duties

• Initiate referrals to ensure appropriate coordination of care.
• Seek the advice of the Medical Director when appropriate, according to policy.
• Assist non-clinical staff in performance of administrative reviews.
• Perform comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
• Maintain regular and predictable attendance.
• Consistently demonstrate compliance with HIPAA regulations, professional conduct, and ethical practice.
• Work to encourage and promote Company culture throughout the organization.
• Perform other duties as may be assigned.

Qualifications

• 3 years Clinical experience preferred.
• 1-2 years of Utilization Review preferred.
• Proficient in Microsoft Office (Outlook, Word, Excel).
• Working knowledge of NCQA preferred.
• Must be able to work in an independent and creative manner.
• Ability to manage multiple projects and priorities.
• Adaptive to high pace and changing environment.
• Customer service oriented.
• Proficient in interpreting benefits, contract language and medical policy/medical review criteria.
• Current, active Compact State license in Nursing (RN).

Physical Requirements

Prolonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required.

Benefits

• 401K (4% Match, Immediate Vesting)
• Accident insurance
• Competitive salary
• Critical Illness Insurance
• Dental Insurance
• Employee Assistance Program
• Flexible Spending Account
• Health & Wellness Program
• Health Savings Account
• Life & AD&D Insurance
• Long Term Disability
• Medical Insurance
• Paid Time Off
• Pet Insurance
• Short Term Disability
• Vision Insurance

Equal Employment Opportunity

HealthOne is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status, or any other status protected by state or federal law.