Utilization Management Registered Nurse

Become a part of our caring community and help us put health first
 The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Use your skills to make an impact
 

Required Qualifications

• Active licensed Registered Nurse (RN) in the state of Virginia or obtain a multi-state license in a state that participates in the enhanced licensure, (eNLC) with no disciplinary action.

• At least 2 years prior clinical experience preferably in an acute care, (Heart, Lung, Critical Care), skilled or rehabilitation clinical setting

• Intermediate to Advanced knowledge using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment.

• Ability to work independently under general instructions and with a team

• strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills,

• Ability to work independently under general instructions and with a team

Preferred Qualifications

• BSN or Bachelor's degree in a related field

• Previous experience in utilization management

• Health Plan experience, Medicare/Medicaid experience

• Bilingual is a plus

Additional Information:

Workstyle: Remote work at Home

Location: Must reside in the state of Virginia or reside in a state participating in the enhanced nurse compact licensure, (eNLC)

Schedule: Must work a minimum of 8 hours between 8:00AM to 5:00 PM Eastern Time, may be required to work rotating holidays or weekends as determined by business needs

Travel: Less than 5% to attend onsite market meetings as business needs

Work at Home Guidance To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

At minimum, a download speed of 25 Mbps and an upload speed …