Clinical UM Nurse
New
United StatesFull-TimeMiddle
Salary$71,100 - $97,800 per year
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Job Details
- Languages
- Bilingual in English and Spanish
- Experience
- 3+ years
- Required Skills
- Microsoft Excel
Requirements
- Active Registered Compact Nurse license (RN) in the home state with no disciplinary action and ability to obtain non-compact licensure.
- 3+ years of Medical Surgery, Heart, Lung, or Critical Care Nursing clinical experience in acute, skilled, or rehab settings.
- Comprehensive knowledge of Microsoft Word, Outlook, and Excel.
- Must have a dedicated workspace lacking interruptions.
- Self-provided internet with minimum 25 Mbps download and 10 Mbps upload speed.
- Willingness to work a rotation including weekends and possible holiday coverage.
- Preferred: Previous experience in utilization management.
- Preferred: Bachelor of Science in Nursing (BSN) or related degree.
- Preferred: Health Plan experience.
- Preferred: Previous Medicare/Medicaid experience.
- Preferred: Bilingual in English and Spanish.
Responsibilities
- Interpret clinical criteria, policies, and procedures to ensure appropriate treatment and services for members.
- Coordinate and communicate with providers, members, and other stakeholders to facilitate care.
- Evaluate medical necessity and quality of care through utilization management processes.
- Maintain confidentiality of member protected health information (PHI) in compliance with HIPAA.
- Perform clinical reviews in a remote, home-office environment.
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