Utilization Review Nurse

Peak Health; Core (WV); On-site; USD 70,000 - 100,000; Full time

Job summary

PHH Peak Health Holdings is seeking a registered nurse with 3+ years of healthcare clinical experience to support care management and utilization management for Medicare/Medicaid populations. The role builds and implements review processes, collaborates with Medical Directors, and educates stakeholders to improve member outcomes and service quality.

Clinical proficiency in InterQual/Milliman Guidelines and knowledge of NCQA regulations are essential.

Qualifications

• Current Registered Nurse license required in the state of service or multi-state license via eNLC.

Responsibilities

• Assist in building and implementing care management review processes (Prior Authorization, Predetermination, Concurrent/Retrospective Reviews).
• Ensure interventions maximize member health outcomes and align with guidelines.
• Collaborate with Medical Directors to improve member and provider network services.
• Educate internal/external stakeholders to improve processes and relationships.
• Collaborate with the medical management team to identify opportunities for coaching and case management.

Skills

InterQual/Milliman Guidelines

Regulatory knowledge

Communication skills

Problem solving

Attention to detail

Microsoft Office

Education

BSN

ASN

Job description

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

• 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).

EXPERIENCE:

• Three (3) years of healthcare clinical experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

• 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.

EXPERIENCE:

• Medical Management for Medicare and/or Medicaid populations.
• Utilization Management experience.

CORE DUTIES AND RESPONSIBILITIES:

The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

• 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.
• Assists with the build and implements all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies.
• Ensures that interventions are collaborative and focus on maximizing the member’s health care outcomes.
• Understands the Peer-to-Peer Review process and works with the Medical Directors to continuously improve member and Provider Network services for this process.
• Educates internal and external stakeholders and partners to continuously improve processes and build network relationships.
• 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.
• Understands the data that is collected within the position, and work with other team members on improving outcomes.
• Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.

PHYSICAL REQUIREMENTS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Standard office environment.

SKILLS AND ABILITIES:

• Working Knowledge of InterQual and/or Milliman Care Guidelines.
• Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning.
• Excellent written and oral communication.
• Problem solving capabilities to drive improved efficiencies and customer satisfaction.

Attention to detail.

• Proficiency with Microsoft Office.

Additional Job Description:

This role may require occasional weekend and holiday work.

Scheduled Weekly Hours:

40

Exempt/Non-Exempt:

Shift:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2403 PHH Medical Management