Utilization Management Nurse

HealthOne Alliance; Dalton (GA); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

401K match

Accident insurance

Dental insurance

Employee Assistance Program

Flexible Spending Account

Health insurance

Life insurance

Paid Time Off

Short Term Disability

Vision insurance

Job summary

HealthOne Alliance is seeking a dedicated Utilization Management Nurse to conduct comprehensive clinical reviews using established criteria. The role emphasizes coordination of care through referrals and collaboration with the Medical Director as needed.

Excellent documentation, attention to detail, and HIPAA compliance are essential. The candidate will manage appeals, pre-certifications, and reviews, applying clinical judgment and contract language to ensure appropriate utilization.

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 independently and creatively.

Responsibilities

• 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 administrative reviews.
• Perform provider and member appeals, denial interpretation, retrospective claim review, and UM pre-certifications and appeals.

Skills

Clinical experience

Utilization Review

Microsoft Office

NCQA knowledge

Independent working style

Multitasking

Customer service

Benefits interpretation

Education

RN license (Compact State)

Tools

Microsoft Word

Excel

Job description

MISSION

Our mission is to enhance well-being by connecting individuals with vital health resources through a compassionate workforce that embodies the spirit of neighbors helping neighbors.

VALUES

HealthOne is guided by a cultural framework that embodies our values and drives our decisions.
Our PURPOSE is to care for people by connecting them to resources that help protect them in health related situations. To fulfill our purpose, we align our PRIORITIES to ensure each decision we make is ethical, empathetic, economical, and efficient. We care for PEOPLE by being welcoming, authentic, truthful, consistent and humble. We are continuously looking for ways to improve our PROCESS and how we get things done.

HealthOne seeks individuals with integrity and heart to embody our values. Whether you’re starting your career or looking to develop additional skills to reach your full potential, HealthOne provides the means to help you achieve your goals.

JOB PURPOSE

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

ESSENTIAL JOB DUTIES

• Initiate referrals to ensure appropriate coordination of care.
• Seek the advice of the Medical Director when appropriate, according to policy.
• Assists non-clinical staff in performance of administrative reviews
• Performing 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.
• Regular and predictable attendance
• Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
• Works to encourage and promote Company culture throughout the organization
• 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

PRE-EMPLOYMENT SCREENING

Drug Screen and Background Check Required

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.