Telephonic Utilization Mgmt RN: Work from home opportunity! Must live within the Hawaiian Islands!-330344
Description
In this rewarding and challenging role, the Utilization Management Nurse is responsible for utilization management and utilization review (on-site or telephonic inpatient care management). Performs reviews of current Acute Inpatient Services and determines medical appropriateness of those services following an evaluation of medical guidelines and benefit determination. Generally work is self-directed and not prescribed. The Utilization Management Nurse works under the direct supervision of an RN or MD.
***This is a work from home opportunity. You must live within the Hawaiian Islands***
Primary Responsibilities:
- Works with less structured, more complex issues.
- Serves as a resource to others.
- Assesses and interprets customer needs and requirements.
- Provides authorizations and/or denials based on clinical documentation review and medical necessity.
- Collaborates closely with the Medical Director for complex cases.
- Develops expertise in a managed care plan Utilization Management process.
- Identifies solutions to non-standard requests and problems.
- Solves moderately complex problems and/or conducts moderately complex analyses.
- Works with minimal guidance.
- Translates concepts into practice.
- Provides explanations and information to others on difficult issues.
- Coaches, provides feedback, and guides others.
- Acts as a resource for others with less experience.
- Other duties as assigned.
Qualifications
Required:
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Current and unrestricted RN license for the State of Hawaii
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Experience working with Medicaid and/or Medicare
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Experience working within the Healthcare and/or Insurance industry
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3 years minimum of clinical experience
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Experience working in utilization management
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Experience working with Milliman and/or Interqual
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Knowledge of ICD 9 codes
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Strong computer proficiency, must be able to type in addition to navigating around a Windows environment
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Strong communication skills, written and verbal
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Strong organizational skills
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Must have problem solving skills; with the ability to systematically analyze problems, draw relevant conclusions and devise appropriate course of action
Additional Qualifications Preferred:
Evercare is part of AmeriChoice, a family of UnitedHealth Group businesses dedicated to improving the health and well-being of Medicaid and Medicare
If you're ready to help make health care work better for more people, YOU can make a historic impact on the future of health care at Evercare. JOIN US!
We contract with states and other government agencies to provide care for over two million individuals. Working with physicians and other care providers, we ensure that our members obtain the care they need with a coordinated approach.
This enables us to break down barriers, which makes health care easier for our customers to manage. That takes a lot of time. It takes a lot of good ideas. Most of all - it takes an entire team of talent. Individuals with the tenacity and the dedication to make things work better for millions of people all over our country.
YOU can be a part of this team. YOU can put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered. APPLY NOW!
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.
Job Clinical Utilization Managemen
Primary LocationUS-HI-Honolulu
Other LocationsUS-HI-Lahaina, US-HI-Waimea, US-HI-Waianae, US-HI-Hilo, US-HI-Wahiawa, US-HI-Kaneohe, US-Hawaii, US-HI-Kailua, US-HI-Mililani, US-HI-Kona, US-HI-Kahului, US-HI-Kihei, US-HI-Lihue, US-HI-Wailuku
Organization AMC Hawaii
Schedule Full-time
Number of Openings 3
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