MagnaCare
Utilization Management Nurse – MagnaCare
BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.
Primary Responsibilities
Performs clinical utilization reviews 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
Identifies potential quality of care issues, service or treatment delays and intervenes 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
Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements
Essential Qualifications
Current Registered Nurse (RN) with state licensure. Must retain active and unrestricted licensure throughout employment
Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
Must be able to work independently
Must be detail oriented and have strong organizational and time management skills
Adaptive to a high pace and changing environment- flexibility in assignment
Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review
Proficient in MCG and CMS criteria sets
Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred
Working knowledge of URAC and NCQA
2+ years’ experience in a UM team within managed care setting
3+ years’ experience in clinical nurse setting preferred
TPA Experience preferred
Employment Type Full-time
Seniority Level Entry level
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Primary Responsibilities
Performs clinical utilization reviews 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
Identifies potential quality of care issues, service or treatment delays and intervenes 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
Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements
Essential Qualifications
Current Registered Nurse (RN) with state licensure. Must retain active and unrestricted licensure throughout employment
Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
Must be able to work independently
Must be detail oriented and have strong organizational and time management skills
Adaptive to a high pace and changing environment- flexibility in assignment
Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review
Proficient in MCG and CMS criteria sets
Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred
Working knowledge of URAC and NCQA
2+ years’ experience in a UM team within managed care setting
3+ years’ experience in clinical nurse setting preferred
TPA Experience preferred
Employment Type Full-time
Seniority Level Entry level
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