UM Specialist (RN) - Remote / Telecommute

Job Overview

Pay Range: $46.76hr - $51.76hr

Requirement/Must Have

• 5+ years Clinical nursing experience.
• 2+ years Care Management.
• Bachelor's Degree in Nursing.
• In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Responsibilities

• Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM, Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references.
• Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors.
• Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care.

Nice to Have

• Working knowledge of managed care and health delivery systems.
• Thorough knowledge of clinical guidelines, medical policies and accreditation and regulatory standards.
• Working knowledge of IT and Medical Management systems, familiarity with web-based software application environment.

Skills

• Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues.
• Strong assessment skills with the ability to make rapid connection with Member telephonically.
• Ability to work effectively with large amounts of confidential member data and PHI.
• Ability to prioritize workload during heavy workload periods.
• Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility.
• Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint.
• Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis.

Qualification And Education

• RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire.
• LPN - Licensed Practical Nurse - State Licensure.
• CNS-Clinical Nurse Specialist Preferred.