Utilization Management Nurse

US Tech Solutions; United States; On-site; USD 70,000 - 80,000; Full time

Job summary

An established industry player is seeking a dedicated clinical evaluator to enhance healthcare quality and compliance. In this role, you will review and interpret clinical documentation, ensuring adherence to regulatory standards while independently coordinating resolutions with clinicians. Your expertise will be crucial in navigating complex healthcare systems and improving operational efficiency. This is an exciting opportunity to make a significant impact in the healthcare sector, contributing to better patient outcomes and streamlined processes within a supportive environment. Join a team that values your skills and offers a pathway to professional growth in a rewarding field.

Qualifications

• 3+ years of clinical experience required, preferably in Managed Care/Medicare.
• Requires an RN with an unrestricted active license.

Responsibilities

• Review and evaluate clinical documentation for compliance with policies.
• Coordinate clinical resolutions with internal/external clinician support.
• Condense complex information into a clear clinical picture.

Skills

Clinical Evaluation

Data Interpretation

Regulatory Compliance

Clinical Documentation Review

Managed Care Knowledge

Education

Registered Nurse License

Job description

This range is provided by US Tech Solutions. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$35.00/hr - $36.00/hr

Duration: 03 months

Summary:

Responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with an unrestricted active license.

Responsibilities:

• Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations. Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation. Data gathering requires navigation through multiple system applications. Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
• Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
• Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.
• Commands a comprehensive knowledge of complex delegation arrangements, contracts, clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.
• Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines.
• Condenses complex information into a clear and precise clinical picture while working independently. Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.

Experience:

• 3 years of clinical experience required - Managed Care/Medicare experience preferred.

Education:

• Provide comprehensive healthcare management services to facilitate appropriate healthcare treatment, effectively manage healthcare costs and improve healthcare program/operational efficiency involving clinical issues.

Skills:

About US Tech Solutions:

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Recruiter Details:

Name: Parth

Email: [e-mail]

Internal Id: 24-09603

Seniority level

• Mid-Senior level

Employment type

• Full-time

Job function

• Health Care Provider
• Industries: Hospitals and Health Care