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Registered Nurse Utilization Management

Divihn Integration Inc.
Hoffman Estates, IL
November 07, 2019


Please submit resumes with rate on W2 hourly for Contract to PERM position. to

Must be Local / who can go for onsite interview. Must be USC or GC holders.

RN Utilization Management

Tampa, FL

If interested, please send resume with desired rate on w2 hourly or salary

Position Summary:

The Utilization Management Nurse Reviewer is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making.

The Utilization Management Nurse Reviewer works with healthcare providers to ensure appropriate approval of plan benefits. This is accomplished by reviewing clinical information provided to assess medical necessity and the appropriateness of the treatment setting through the application of appropriate policies and criteria (i.e. Milliman). Case assignments may fall in various areas, such as concurrent review of inpatient services, discharge planning, retrospective review, and special needs facilities (SNF).

Minimum Qualifications:

· Current Active and Unrestricted Nursing License required ( Associate Degree, Nursing Diploma or Bachelor’s degree in Nursing)

· 3 years combined clinical and utilization management experience in a managed health care plan preferred

Preferred Qualifications:

· Bachelor’s Degree in Nursing preferred with 3-5 years of clinical experience in Utilization Review

· Required experience in utilization management to include utilization review, concurrent review, discharge planning, transitional care and Skilled nursing review.

· Knowledge of Medicaid, Commercial or Medicare Managed Care programs and regulations

Experience & Education:

· Experience using and applying InterQual & MCG clinical guidelines

· Comprehensive understanding of standards such as NCQA, URAC, CMS (Medicare/Medicaid) and their application in a managed care setting

Special Skills

· Excellent analytical-thinking/problem-solving skills

· Ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads

· Excellent interpersonal skills required


· Intermediate Microsoft Word, Excel, Outlook & PowerPoint skills

Primary Responsibilities:

· Performs utilization management reviews in accordance with federal and state regulations

· Maintains compliance with regulatory changes affecting utilization management

· Perform UM reviews (prospective/concurrent/retrospective) for inpatient services according to the NCQA, URAC, CMA & DOH standards and client requirements and/or policies

· Reviews UM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer

· Adheres to Department of Labor, state and UM timeframe requirements per contract

· Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results

· Tracks status of all utilization management reviews in progress

· Releases UM determinations to claim stakeholders following client-established protocols

· Works closely with management team in the ongoing development and implementation of utilization management programs

· Certifies reviews that meet clinical review criteria/guidelines

· Adheres to quality standards and UM guidelines

· Maintains all required utilization management review documentation in the UM software in a timely manner

· Refer cases to case management as indicated/appropriate

· Responds to inbound telephone calls pertaining to UM reviews in a timely manner, following client-established proto

· Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols

· Maintains acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives

· Learns new methods and services as the job requires

· Advises supervisor of any potential problems as they become evident

· Manages assigned workload within established performance & productivity standards

· Attends meetings to achieve departmental goals and objectives

· Able to work rotational shifts with adherence to schedule a must, including evenings, weekends, holidays and overtime as necessary

· Performs other projects and duties as assigned