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Clinical Review RN (Utilization Management) - Remote ID-12136

Job Responsibilities

  • 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 reviews
  • Performing 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.
  • Occasional weekend work may be required.
  • Must be able to pass Windows navigation test.
  • Testing/Assessments will be required for Digital positions.
  • Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions.

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Job Qualifications

License

  • Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.

Experience

  • 3 years - Clinical experience required

Skills\Certifications

  • Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
  • Working knowledge of URAC, NCQA and CMS accreditations
  • Must be able to work in an independent and creative manner.
  • Excellent oral and written communication skills
  • Strong interpersonal and organizational skills
  • Ability to manage multiple projects and priorities
  • Adaptive to high pace and changing environment
  • Customer service oriented
  • Superior interpersonal, client relations and problem-solving skills
  • Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria

 

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