Utilization Management Nurse

Job Description

Job Description

Job Title:   Utilization Management Nurse

Reports To: Manager of Utilization Management

Employment Type: Full-Time, Exempt 

Brief Description of Duties:    

This position is reserved for a licensed Registered Nurse who will perform the Utilization Management (UM) services for SIHO (and affiliated business lines’) members. This individual’s primary role is to ensure that health care services are administered with quality, cost effectiveness, and compliance to plan guidelines are maintained. By performing review of services prospectively, retrospectively, and throughout the episode of care, the UM nurse will make coverage determinations influencing how services are allocated to SIHO’s various member populations.  A candidate’s ability to perform quality reviews within strict efficiency standards is required for this position.  Key responsibilities are as follows: 

- Pre-service, concurrent, and post-service review of necessity of health care services utilizing enrollee medical records and established guidelines set by SIHO and/or state and federal (CMS) guidelines

- Interaction with the member, health care provider, and/or other care team members to complete reviews in most time-efficient manner

- Interaction with the SIHO Medical Director as needed to ensure proper medical necessity decisions are made in a timely manner

- Appropriate documentation of the entire review process utilizing the established documentation system and desk procedures to guarantee accurate reporting metrics and data integrity

- Complete case review and elevation to determinations that are rendered within the contractual and regulatory turnaround times established by SIHO and CMS

- Assist to resolve problems and provide guidance to members of the team and cohorts

-Interpret and abide by organizational policies and procedures; review work regularly to ensure that policies and guidelines are appropriately applied

-Act as a clinical resource to the department and other organization members for services pertaining to medical management, utilization review, and medical necessity

- Act and perform within the scope of professional nursing practice; is responsible in supporting and participating in department strategies and efforts focused on quality improvement

- Responsible for the early identification and assessment of members for inclusion in disease management or care management programs

- Assist in the identification and reporting of Potential Quality of Care concerns and Fraud, Waste and Abuse incidents

- Work as an interdisciplinary team member within Medical Management for all lines of business and commercial group plans 

Minimum Skills Requirement:

- Registered Nurse with current, unrestricted license in primary state of employment (position may require additional licensing in other states as necessary)Previous UM or Health Plan experience highly preferred

- Desire to work in a fast-paced environment with focus on efficiency while maintaining quality

- Self-directed organization and prioritization skills, and independent time management skills required

- Sound clinical background with experience in the clinical field

- Excellent verbal and written communication skills

- Microsoft Office Experience: Outlook, Word, Excel

We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.