Telephonic Utilization Management Nurse (South Central Region)
About the position The Utilization Management Nurse 2 plays a crucial role in the healthcare system by utilizing clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. This position requires a blend of clinical knowledge, communication skills, and independent critical thinking to interpret criteria, policies, and procedures, ensuring that members receive the best and most appropriate treatment, care, or services. The nurse will coordinate and communicate with providers, members, and other parties to facilitate optimal care and treatment, as well as assist with appropriate discharge planning, addressing social determinants, and closing care gaps. In this role, the nurse will be expected to understand the department, segment, and organizational strategy and operating objectives, including their linkages to related areas. The nurse will make decisions regarding their work methods, often in ambiguous situations, requiring minimal direction while receiving guidance when necessary. Following established guidelines and procedures is essential to ensure compliance and quality of care. This position is remote, allowing the nurse to work from home while maintaining a dedicated workspace that protects member PHI/HIPAA information. The work schedule is Monday to Friday from 8 am to 5 pm CST, with the possibility of overtime or weekend work based on business needs. The role offers a competitive salary and is eligible for a bonus incentive plan based on individual and company performance. Responsibilities Utilize clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. , Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment. , Assist with appropriate discharge planning, addressing social determinants, and closing care gaps. , Interpret criteria, policies, and procedures to provide the best treatment and care for members. , Make independent decisions regarding work methods in ambiguous situations with minimal direction. , Follow established guidelines and procedures to ensure compliance and quality of care. Requirements Licensed Registered Nurse (RN) Compact license required, with no disciplinary action. , At least 3 years of varied clinical nursing experience. , Utilization management experience, including following MCG/Milliman or Interqual guidelines. , Prior clinical experience in an acute care, hospital, skilled, or rehabilitation clinical setting. , Comprehensive knowledge of Microsoft Word, Outlook, and Excel. , Ability to work independently under general instructions and collaboratively with a team. , Passion for contributing to an organization focused on improving consumer experiences. Nice-to-haves Bachelor's degree in nursing (BSN). , CCM Certification. , Health Plan experience. , Previous Medicare/Medicaid Experience. , Call center or triage experience. Benefits Medical, dental, and vision benefits. , 401(k) retirement savings plan. , Paid time off, including company and personal holidays, volunteer time off, paid parental and caregiver leave. , Short-term and long-term disability insurance. , Life insurance. , Opportunities for personal wellness and smart healthcare decisions. Apply Job!