Utilization Management Nurse

Roles And Responsibilities

• Coordinates the utilization review process for each treatment request.
• Provides clinical oversight and serves as a resource for non-clinical staff.
• Conducts initial clinical review for medical necessity against approved evidence-based guidelines.
• Evaluates need for continued or alternative treatment with provider.
• Discusses treatment options with requesting provider.
• Documents utilization review components within the Ethos Utilization Management System per State, Federal and URAC requirements, including data collection for analysis and trending.
• Refers, coordinates and interacts with peer clinical reviewers.
• Facilitates peer discussion during peer clinical review process.
• Partners with medical providers to promote best patient outcomes.
• Adheres to Ethos Policies and Procedures and URAC standards as appropriate to job functions.
• Assists in promoting and furthering the objectives of the Quality Management Program.
• Maintains confidentiality and security in all aspects of performance.
• Performs other related duties incidental to the work described herein.

Qualifications

Education/Licensure/Certification

• Completion of formal training in a health care field; and
• Active, unrestricted professional license or certification to practice as a health professional in a state or territory of the United States:
• An associate degree or higher in a health care field (RN); OR
• State license or state certificate in a health care field (LVN/LPN).
• Certified Case Manager (CCM), Health Care Quality & Management (HCQM) or equivalent certification preferred.

Experience

• 2 years of clinical nursing experience (direct patient care, administrative or combination post-licensure).
• 1-year experience with workers’ compensation/utilization management preferred.

Skills/Knowledge

• Knowledge of workers’ compensation laws and regulations (preferred).
• Discretion and confidentiality.
• Good customer service skills.
• Strong oral and written communication skills.
• Computer knowledge required, including Microsoft Office products.
• Able to perform as part of a team.
• Analytical and interpretive skills.
• Strong organizational skills.
• Excellent interpersonal skills.
• Good negotiation skills.
• Ability to multi-task.