Utilization Management RN WVU Medicine · Remote US

QuickCruit, Inc.; Northern (KY); Hybrid; USD 70,000 - 100,000; Full time

Job summary

QuickCruit, Inc. is seeking a Utilization Management RN to collaborate with the Medical Director and Health Plan Manager. You will drive reductions in care variance, ensure timely discharges, and refer members to plan resources to meet care conditions.

In this remote U.S. role, you will contribute to care management review processes and educate stakeholders, supporting an integrated medical management team focused on optimal patient outcomes.

Qualifications

• Current Registered Nurse license in the state where services are provided or multi-state license via eNLC.
• Three (3) years of healthcare clinical experience.
• Bachelor's Degree in Nursing or ASN; BSN completion within three years of hire.
• Medicare and/or Medicaid medical management experience.
• Utilization Management experience.

Responsibilities

• Assist with building and implementing care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews).
• Develop and apply care management reviews per criteria and clinical guidelines.
• Ensure interventions maximize member health care outcomes.
• Collaborate with Medical Directors to improve member and Provider Network services in Peer-to-Peer Review.
• Educate internal and external stakeholders to improve processes and build network relationships.
• Work with medical management team to identify members who may benefit from coaching or case management.

Skills

RN license

Healthcare experience

BSN/ASN

eNLC license

Utilization Management

Education

Bachelor's Degree in Nursing

ASN (Associate of Science in Nursing)

BSN in progress

Job description

# Utilization Management RNWVU Medicine · Remote USTailor My ResumeStart free. No credit card.### Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position.Responsible for working in collaboration with the Medical Director on driving the decrease in care variance, to ensure timely discharges, and to refer members to other plan resources to meet their care conditions. Reports to the Health Plan Manager of Utilization Management. This position will be an integral member of the health plan’s medical management team. This position is a collaborative member of the Medical Management team.### Qualifications* 1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).* 1. Three (3) years of healthcare clinical experience.* 1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); Currently enrolled in a BSN program and BSN completion within three (3) years of hire.* 1. Medical Management for Medicare and/or Medicaid populations.* 2. Utilization Management experience.### About the JobCORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. Other duties may be assigned.* 1. Assists with the build and implements care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards.* 2. Assists with the build and implements all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies.* 3. Ensures that interventions are collaborative and focus on maximizing the member’s health care outcomes.* 4. Understands the Peer-to-Peer Review process and works with the Medical Directors to continuously improve member and Provider Network services for this process.* 5. Educates internal and external stakeholders and partners to continuously improve processes and build network relationships.* 6. Works collaboratively with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.