Utilization Management Nurse

Integrated Resources, Inc is a premier staffing firm recognized as one of the tri-state's most well-respected professional specialty firms. IRI has built its reputation on excellent service and integrity since its inception in 1996. Our mission centers on delivering only the best quality talent, the first time and every time. We provide quality resources in four specialty areas: Information Technology (IT), Clinical Research, Rehabilitation Therapy, and Nursing.

Job Description

Location: Downers Grove, IL

Responsibilities:

1. Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities.
2. Develop, implement, and support Health Strategies, tactics, policies, and programs that ensure the delivery of benefits and establish overall member wellness and successful and timely return to work.
3. Manage services, strategies, policies, and programs, including network management, clinical coverage, and policies.
4. Utilize clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program. Requires an RN (consideration for LCSW) with an unrestricted active license.
5. Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services/benefits for members using clinical experience and skills.
6. Gather clinical information and apply appropriate clinical criteria, guidelines, policies, procedures, and clinical judgment to make coverage determinations/recommendations along the continuum of care.
7. Communicate with providers and other parties to facilitate care/treatment.
8. Identify members for referral opportunities to integrate with other products, services, and/or programs.
9. Identify opportunities to promote quality and effectiveness of healthcare services and benefit utilization.
10. Consult and lend expertise to internal and external stakeholders in the coordination and administration of the utilization/benefit management functions.

Background/Experience Desired

• Managed Care experience preferred.
• 3-5 years of clinical experience required.

Education and Certification Requirements

• RN with current, unrestricted state licensure required. Consideration for LCSW.

Additional Information

• Proficiency with computer skills, including navigating multiple systems and keyboarding.
• Effective verbal and written communication skills.
• Ability to multitask, prioritize, and adapt in a fast-paced environment.
• Sedentary work involving sitting, talking, listening, and working at a computer for extended periods.
• Ability to perform close inspection of handwritten and digital documents and monitor screens.
• Typical office environment with productivity and quality expectations.
• Experience in Behavioral Health required; Managed Care experience preferred.
• Onsite location: Downers Grove.
• Work hours: 8:00 am to 5:00 pm, with weekend rotation among clinicians approximately every 1.5 to 2 months.
• Ability to create and process clinical documentation for Behavioral Health cases via live phone queue, including clinical determinations communicated to providers.
• Required to have computer skills and toggle between up to 5-6 applications/systems simultaneously.