Utilization Management Nurse - Care & Authorizations

Maniilaq Association; Kotzebue (AK); On-site; USD 90,000 - 120,000; Full time

Job summary

The Utilization Management Nurse (UMN) at Maniilaq Association in Kotzebue, Alaska, performs utilization review and risk management activities within the Nursing Division. The UMN coordinates with departments on DME, pharmacy prior authorizations, and supports the treatment team in patient care planning and monitoring.

Reporting to the Chief Nursing Officer, the role involves quality improvement participation, program development, and adherence to regulatory standards.

Qualifications

• Current RN licensure with at least two years in Case Management/Utilization Review/Discharge Planning or Quality Improvement.
• Knowledge of acute and chronic illnesses, specialty clinic procedures, and community health nursing.
• Proficient with Cerner and Microsoft Office; able to work autonomously and collaborate with diverse teams.

Responsibilities

• Coordinate IPC4 process in Medicare/Medicaid and private insurances.
• Assist revenue procurement by ensuring correct insurance approvals and identifying alternate funding sources.
• Chairs Quarterly Utilization Review Committee meetings to improve resource utilization and patient care.
• Submits quarterly reports to CMO and CNO for Board of Director meetings.
• Collaborates with Coders and Billers to ensure accurate, timely billing information.
• Oversees development and maintenance of a resource database of Federal, State, community, and institutional resources.
• Participates in Medicaid Task Force and Quality Improvement projects.
• Educates clinical and administrative staff on risk awareness, safety protocols, and compliance requirements.
• Coordinate and facilitate prior authorizations for DME and high-cost medications; monitor appeals if denied.

Skills

Case management

Utilization review

Discharge planning

Quality improvement

Regulatory knowledge

Autonomous work

Education

Registered Nurse licensure (RN)

Tools

Cerner

Microsoft Office

Job description

The Utilization Management Nurse (UMN) at Maniilaq Association in Kotzebue, Alaska, performs utilization review and risk management activities within the Nursing Division. The UMN coordinates with departments on DME, pharmacy prior authorizations, and supports the treatment team in patient care planning and monitoring.

Reporting to the Chief Nursing Officer, the role involves quality improvement participation, program development, and adherence to regulatory standards.