Utilization Management Nurse

MISSIONOur mission is to enhance well-being by connecting individuals with vital health resources through a compassionate workforce that embodies the spirit of neighbors helping neighbors.

VALUESHealthOne is guided by a cultural framework that embodies our values and drives our decisions.Our PURPOSE is to care for people by connecting them to resources that help protect them in health related situations. To fulfill our purpose, we align our PRIORITIES to ensure each decision we make is ethical, empathetic, economical, and efficient. We care for PEOPLE by being welcoming, authentic, truthful, consistent and humble. We are continuously looking for ways to improve our PROCESS and how we get things done.

HealthOne seeks individuals with integrity and heart to embody our values. Whether you’re starting your career or looking to develop additional skills to reach your full potential, HealthOne provides the means to help you achieve your goals.

JOB PURPOSEThe Utilization Management Nurse performs comprehensive clinical reviews of requested services utilizing clinical criteria, received through various mechanisms.

ESSENTIAL JOB DUTIES

    Initiate referrals to ensure appropriate coordination of care.Seek the advice of the Medical Director when appropriate, according to policy.

    Assists non-clinical staff in performance of administrative reviewsPerforming comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.

    Regular and predictable attendanceConsistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice

    Works to encourage and promote Company culture throughout the organizationOther duties as may be assignedQUALIFICATIONS

    3 years Clinical experience preferred1-2 years of Utilization Review preferred

    Proficient in Microsoft Office (Outlook, Word, Excel)Working knowledge of NCQA preferred

    Must be able to work in an independent and creative manner.Ability to manage multiple projects and priorities

    Adaptive to high pace and changing environmentCustomer service oriented

    Proficient in interpreting benefits, contract language and medical policy/medical review criteriaCurrent, active Compact State license in Nursing (RN). 

PHYSICAL REQUIREMENTSProlonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required.

BENEFITS401K (4% Match, Immediate Vesting)

Accident insuranceCompetitive salary

Critical Illness Insurance

Dental InsuranceEmployee Assistance Program

Flexible Spending Account

Health & Wellness Program

Health Savings Account

Life & AD&D Insurance

Long Term Disability

Medical InsurancePaid Time Off

Pet InsuranceShort Term Disability

Vision Insurance

PRE-EMPLOYMENT SCREENINGDrug Screen and Background Check Required

HEALTHONE IS AN EQUAL OPPORTUNITY EMPLOYERAll qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status, or any other status protected by state or federal law.