RN Utilization Management Specialist at Managed Care Staffers
Park Ridge, IL 60068
About the Job
Our client, a growing Medicare Advantage Plans Ins. Co. located in Park Ridge; IL has an immediate need for an experienced partially remote, direct hire full-time IL Licensed RN UM Specialist.
Hours for this position: M-F (8:30am-5:00pm) & one Sat/mo. 9am -1pm.
We understand that you cannot submit any comments or text with your resume. If you apply through Monster, please send a separate email to cjepsen[at]managedcarestaffers.com with the answers to the following questions in order to be considered for this position:
- Are you an IL Licensed Registered Nurse?
- How many years of utilization review experience do you have?
- How many years of Milliman criteria experience do you have?
- What is your desired minimum hourly compensation?
Do you have experience performing UM with Medicare Advantage Plans?
- Is Park Ridge, IL a good location for you?
Job Responsibilities
- Performs prospective, initial, concurrent, and retrospective reviews for all requested services to include but not limited to the following: inpatient admissions, concurrent reviews, discharges, (DME), Part B drugs, & outpatient and home health services.
- Monitors level and quality of care of services being provided and approved.
- Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
- Under the supervision of the UM Team Lead and Medical Director, evaluates and provides feedback as needed to treating physicians regarding a member's discharge and home care plans, available covered services including identifying alternative levels of care that may be covered.
- Monitors the UM system to assure compliance with turnaround time frames.
- Coordinates an interdisciplinary approach to support continuity of care. Provides UM, transfer coordination, discharge planning, and issuance of all appropriate authorizations
- Responsible for the early identification and assessment of members for potential inclusion in a comprehensive care coordination program. Refers members for care coordination accordingly.
- Actively participates in the discussion and notification processes that result from the clinical utilization reviews with members or members’ representatives, facilities, requestors, and service providers.
- Prepares CMS-compliant notification letters of NON-certified and negotiated days and services within established time frames.
- Assists in the identification and reporting of Potential Quality of Care concerns.
Job Qualifications
- Licensed Registered Nurse
- Experience in the application of Milliman criteria or other evidence-based medical criteria.
- 2 – 4 years utilization review and/or managed care experience is preferred.
- Knowledge of medical problems encountered with Seniors.
- Working knowledge of Medicare Advantage Plans.
- Strong computer skills – Microsoft Office Suite & communication and interpersonal skills.
If you or anyone you know is interested, qualified and currently seeking employment please e-mail an updated resume to us for immediate review and consideration.