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The UM Nurse manages providers, members, or care manager generated requests for medical services and renders clinical determinations in accordance with Hamaspik Choice policies as well as applicable state and federal regulations. UM Nurse delivers timely notification detailing Hamaspik Choice clinical decisions. Participates in UM review process of claims.
Essential Responsibilities:
· Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria.
· Utilizes Plan approved evidence based data set to make decisions
· Able to match member care needs to available resources at the appropriate level of care and make adjustments if necessary
· Consults with Medical Director to determine the appropriate next steps for services that require further review
· Assures that case documentation for each decision is complete, including related correspondence.
· Maintains timely, complete and accurate documentation in compliance with Hamaspik Choice policies and procedures
· Gathers and summarizes data for reports
· Support Quality and Performance Improvement Initiatives
· Conducts utilization review – prospective, concurrent and retrospective
· Participates in appeal process
Specific Knowledge, Skills, and Abilities:
· Valid New York State, unrestricted, RN license
· Bachelor’s Degree (BSN) preferred
Work Remotely
Job Type: Full-time
Pay: $39.00 - $40.00 per hour
Benefits:
Schedule:
Experience:
License/Certification:
Ability to Relocate:
Work Location: In person
Full Time
$91k-114k (estimate)
03/15/2023
07/30/2024
The job skills required for Utilization Review Nurse include Initiative, etc. Having related job skills and expertise will give you an advantage when applying to be an Utilization Review Nurse. That makes you unique and can impact how much salary you can get paid. Below are job openings related to skills required by Utilization Review Nurse. Select any job title you are interested in and start to search job requirements.
The following is the career advancement route for Utilization Review Nurse positions, which can be used as a reference in future career path planning. As an Utilization Review Nurse, it can be promoted into senior positions as a Clinical Outcomes Manager that are expected to handle more key tasks, people in this role will get a higher salary paid than an ordinary Utilization Review Nurse. You can explore the career advancement for an Utilization Review Nurse below and select your interested title to get hiring information.