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Health Services - Utilization Management Specialist
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Job Description
- Req#: 26-02273
Employer Industry: Healthcare Consulting
Why consider this job opportunity:
- Opportunity for career advancement and growth within the organization
- Collaborative work environment with a focus on clinical expertise
- Engage in meaningful work that impacts patient care and outcomes
- Supportive team structure with resources for professional development
- Flexible work arrangements may be available
What to Expect (Job Responsibilities):
- Perform prospective, concurrent, and retrospective reviews for authorization and appropriateness of care
- Analyze clinical information and regulatory requirements to determine the appropriateness and authorization of services
- Conduct research and analysis of diseases, treatments, and technologies to support clinical decisions
- Collaborate with medical directors and other departments to ensure appropriate benefit application
- Make referrals and provide assistance to members and providers regarding care options
What is Required (Qualifications):
- Bachelor's Degree in Nursing
- 5 years of clinical nursing experience and 2 years of care management experience
- RN - Registered Nurse State Licensure or LPN - Licensed Practical Nurse State Licensure required
- Strong assessment and communication skills to engage with members and healthcare professionals
- Ability to work with confidential member data and prioritize workload effectively
How to Stand Out (Preferred Qualifications):
- Working knowledge of managed care and health delivery systems
- Familiarity with clinical guidelines, medical policies, and regulatory standards
- Experience with IT and medical management systems
- Clinical UM expertise and knowledge of regulatory compliance
- CNS - Clinical Nurse Specialist certification preferred
#HealthcareConsulting #UtilizationManagement #ClinicalNursing #CareerGrowth #HealthCareProfessionals
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