Clinical Utilization Management Nurse Reviewer
This includes identification, assessment, planning, implementation/facilitation, coordination and evaluation of health related service options.
These activities require interfacing with members, providers, clinics, medical directors, intake staff, case managers and other departments within the company.
Performance is primarily measured by various quality audits, meeting regulatory requirements including but not limited to turn around times, documentation standards, desired interventions impacted, volume of events/cases managed, and ad hoc feedback from members and providers.
General working knowledge of how various health care services link together (the health care continuum).
Experience working with multiple age groups, medical, surgical background and a generalized level of understanding across specialty care areas.
Strong customer service skills, strong decision making skills, active, listening skills, patience, independence and excellent organizational skills.
Ability to think creatively, negotiate and access resources
Excellent verbal and written skills.
Ability to work independently.
Highly organized, time management skills, requires ability to make decisions under stress and manage multiple complex issues on a daily basis.
Professional RN license in MN required.
Certified Case Manager (CCM) preferred.
BSN or BS/BA preferred with a minimum of three years clinical experience or licensed professional with five years clinical experience.
Managed care experience preferred.
Previous case management or utilization management experience and a broad base of clinical/hospital experience