Utilization Management Nurse - 216041

Medix is currently hiring RN UM nurses to do outpatient reviews for a health plan. We are looking for someone that can start July 14th and be comfortable using their own equipment. The position is a contract with potential to hire.

The Health Plan provides Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization performs medical necessity reviews on prior authorization requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.

Perform prospective utilization reviews and first level determinations for members using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures. Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments. Collaborates with healthcare partners to ensure timely review of services and care. Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed. Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate. Triages and prioritizes cases and other assigned duties to meet required turnaround times. Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations. Communications determinations to providers and/or members in compliance with regulatory and accreditation requirements. Experience with outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.