Utilization Management Nurse

SIHO Insurance Services; United States; Remote; USD 85,000 - 120,000; Full time

Job summary

SIHO Insurance Services seeks a licensed Registered Nurse for the Utilization Management Nurse role. You will perform prospective, concurrent, and retrospective reviews to ensure medical necessity and CMS guideline adherence, coordinating with members and providers to determine coverage decisions.

The role requires strong clinical judgment, efficient time management in a fast-paced environment, and proficiency with Microsoft Office.

Qualifications

• RN with current, unrestricted license in primary state of employment.
• Prior UM or health plan experience preferred.
• Ability to work in a fast-paced environment while maintaining quality.
• Self-directed organization and prioritization skills, and independent time management.
• Excellent verbal and written communication skills.
• Microsoft Office experience: Outlook, Word, Excel.

Responsibilities

• Pre-service, concurrent, and post-service review of medical necessity per guidelines.
• Interact with member, provider, and care team to complete reviews efficiently.
• Coordinate with SIHO Medical Director to ensure timely determinations.
• Document the review process accurately in the established system.
• Ensure determinations are rendered within contractual and CMS turnaround times.
• Identify and report Potential Quality of Care concerns and Fraud, Waste and Abuse.

Skills

Utilization Review experience

Strong communication

Time management

Microsoft Office proficiency

Education

Registered Nurse license (unrestricted)

Tools

Microsoft Office (Outlook, Word, Excel)

Job 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