UM Clinical Specialist RN - Physical Health (Full-time Remote, North Carolina Based)

The Utilization Management (UM) Clinical Specialist RN for physical health (PH) independently assesses the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, and out of network services, monitors consumer treatment through ongoing and continuous review to ensure that services are delivered based on consumer need and established clinical guidelines, and identifies and follows-up on clinical cases of concern and high-risk/special needs consumers to ensure enrollees are linked to appropriate treatment resources. The UM Clinical Specialist RN - PH may represent the unit in cross agency collaborative needs. This position is fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office (Morrisville, NC) may be required. Some holidays and weekends maybe required.

Assesses the medical necessity of services: Independently conduct medical necessity reviews of service requests submitted by service providers against developed clinical guidelines within contractually mandated turn-around times Ensure authorized services address appropriate service needs, intensity of service outcomes, and alternatives for consumers Provide a consistent application of medical necessity criteria for physical health services that promotes a holistic review of the member’s needs Conduct pre-certification, concurrent, and retrospective reviews to ensure compliance with medical policy, member eligibility, benefits, and contracts Conduct utilization reviews to monitor adherence to clinical practice guidelines and best practice standards Notify members of adverse benefit determinations while preserving members’ Due Process rights Ensure compliance with performance measures outlined within all accrediting body standards Perform other related duties as required by the immediate supervisor or other designated Alliance Health administrators Compliance: Comply with utilization management and quality improvement policies and procedures, utilization review laws and regulations, state standards Comply with Utilization Management Department focus on timeliness, effectiveness, quantity, quality, and cost of services for eligible enrollees Coordinate and Implement UM Processes: Participate in the integration of the department and its functions into the organization’s primary mission Take part in the Utilization Management Department collaboration to ensure an integrated department with Physical Health and Behavioral Health Collaborate with other departments: Monitor for undesirable performance or deviations of practice standards that may have a negative impact on consumers. Respond through additional follow-up with consumer and providers, provider technical assistance and/or referral to other departments within the MCO. Maintain open, timely communication with staff, providers, community agencies and other stakeholders