Utilization Management Nurse

Utilization Management: Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards. Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.Communication: Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.Compliance: Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety. Workflow: Proactively and efficiently work incoming and outbound calls and/or queues from multiple sources within mandated requirements.Knowledge: Remain current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.Other duties as assigned.

Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding 4. Experience in utilization management and/or medical review preferred. Specialized Knowledge & SkillsAbility to prioritize and make sound nursing judgments through critical thinkingExcellent verbal and written communication skillsAbility to build collaborative relationshipsAttention to detailsAbility to interpret complex documentation