Medicare Clinical Predetermination Nurse
Must be willing and able to work Monday through Friday, 9am - 5:30pm EST or CST with occasional holiday rotation.
Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours.
- Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
- Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care.
- Communicates with providers and other parties to facilitate care/treatment
- Identifies members for referral opportunities to integrate with other products, services and/or programs
- Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
Required Qualifications
- 3+ years of experience as a Registered Nurse
- Must have active current and unrestricted RN licensure in state of residence
- 1+ years of Med/Surg experience
- 1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel)
- Must be willing and able to work Monday through Friday, 9:00am to 5:30pm eastern or central time with occasional holiday rotation. Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours
Preferred Qualifications
- Prior Authorization or Utilization Management experience
- Managed care experience
- Experience using MedCompass
- Ambulatory surgery experience
Education
Associates degree required
BSN preferred
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is
$29.10 - $62.32