Humera - Administrative and Professional Staffing

Clinical Utilization Management Nurse Reviewer

Minnetonka, MN, United States
Contact For Rate
Feb 21, 2018
Feb 27, 2018
Job Type
Employment Status
Full Time
Humera is seeking a Clinical Utilization Management Nurse Reviewer! The Clinical Utilization Management Nurse Reviewer is responsible for the analysis of trends, which may be identified through the review of cases, and for addressing these issues by recommending revision for medical policy and utilization management and/or clinical appeals policy revision. This person supports in the development, planning and implementation of departmental and cross- departmental projects; which improve the operations of other proficiency and promotes excellence. This is a long term opportunity!

Process Initiation and Evaluation (40%)
  • Works with providers and internal business segments to support member's needs
  • Streamlines the health delivery process to focus on the best treatment approaches for the member
  • Maximizes the timely provision of care
  • Minimizes the utilization of>
  • Coordinates delivery of services in congruence with regulatory requirements)
Communication (20%)
  • Promotes and participates in an achievement-oriented climate for National Care Coordination
  • Participates and supports efforts to provide clarity regarding decisions and provide appropriate conflict resolution techniques./li>
  • Collaborates with all business segments affiliated with our client./li>
Data Systems (10%)
  • Demonstrates knowledge and proficiencies of notification / prior authorization requirements
  • Demonstrates knowledge and proficiencies of required electronic systems (including but not limited to Iset, Q-star, CCS, KN, KL, and Right fax.)
Projects/Team Accountabilities (20%)
  • Participates in establishment and maintenance of effective processes by which to administer clinical benefits./li>
  • Participates/collaborates with internal training cross-departmental projects and coaching.
  • Assists in the identification and resolution of problems as evidenced by activities such as quality improvement processes
  • Participates in tracking and trending of data uncovering root causes for over-turns and implementation of improvement plans
  • Completes projects and assignments as directed
  • Participates in committees or projects as assigned
  • Takes accountability for attending team meetings, 1:1 meetings and performance review of day to day work
Policy and Procedures (10%)
  • Assists with development of new or revisions of existing work flows and or SOP?s to assure accuracy
  • Completes policy reviews and trainings in a timely manner to assure accuracy in process and that compliance standards are met
  • Complies with all department policies and regulatory requirements

Education Level:
  • BSN or BS/BA preferred with a minimum of three years clinical experience or licensed professional with five years clinical experience.
  • Nursing Major
  • 3 years of experience required
Specific types of experience required
  • Previous utilization management experience and/or clinical/hospital experience
  • RN License in MN
  • 3-5 years Medical knowledge and background
  • Critical thinking skills
  • Ability to organize and present case in logical, sequential order
  • Attention to detail and accuracy
  • Flexibility in managing changes in work and environment
  • Excellent written and verbal communications
  • Innovative problem-solving skills
  • Able to focus on a variety of issues at one time
  • Relates well to internal and external customers
  • Demonstrates ability to use Microsoft Office suite
  • Strong customer service skills focus
  • Ability to think creatively, negotiate and access resources

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