Senior Utilization Management Nurse

Details:
Under minimal supervision, provides medical and/or behavioral health utilization management for members of Medical Plan in accordance with the schedule of benefits and network criteria defined by the Plan’s various lines of business and Center of Medicare & Medicaid Services (“CMS”) regulatory requirements. Completes clinical review to determine whether a request can be approved using nationally recognized criteria such as InterQual or MCG, or requires additional review by the Plan’s Medical Director.

MINIMUM QUALIFICATIONS:

Education:
Bachelor’s degree in Nursing. A combination of education and experience may be substituted for the B.S.N. requirement.

Experience:
Typically, three years of medical utilization management experience working with a health insurance plan, hospital, skilled nursing facility, or surgical center. Managed Care experience is highly preferred.

Responsibilities:
• Facility seeks 2 F/T RN Case Managers for excellent contract working in Managed Care department.
• Must have BSN, 3 years’ experience in medical utilization management, and experience working with a health insurance plan.
• Managed Care experience is preferred however hospital experience is also considered.
• Seeking highly skilled individual with experience with InterQual and MCG.
• Provides medical and/or behavioral health utilization management for members of facility medical plan in accordance with the schedule of benefits and network criteria defined by the Plans various lines of business and Center of Medicare & Medicaid Services.

Regards,

Riya Khem

Life Science Recruiter

Integrated Resources, Inc.

IT Life Sciences Allied Healthcare CRO

(Direct) 732-844-8721 | (W) 732-549-2030 x 311 | (F) 732-549-5549

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