Job Details
Medix is looking for a self-motivated and passionate RN for our Full-Time Remote Utilization Management Nurse with a Health Plan on their Commercial team. This position requires previous Utilization Review or Utilization Management experience due to it being 100 percent remote. The company will not be able to train candidates with no prior UM/UR experience. Must have MCG experience. See below for more details!
Hours: Sunday - Thursday or Tuesday - Saturday(8am - 5pm)
Training: Monday - Friday (8am-5pm)
Equipment: Apple products (must be comfortable using)
Summary/objective
As a Utilization/Clinical Review Nurse, you will determine the medical appropriateness of inpatient and outpatient services by reviewing clinical information and applying evidence-based guidelines. You will also interact with the health plan providers, members, and internal service team to obtain necessary information and communicate approval determinations. This role has potential to flip to a direct hire after the contract is completed.
Primary Duties and Responsibilities :
- Collect relevant medical information (via telephone and fax) and apply the appropriate evidence-based guidelines and medical policies to determine medical necessity which could include Health Plan's Clinical Guidelines, Milliman Care Guidelines, Hayes, UpToDate, etc.
- Meet required decision-making timeframes, including promptly triggering escalation for cases requiring physician review
- Follow documentation guidelines for clear and concise decision-making within our utilization review tracking platform
- Use the health plan's tools and processes to perform and properly track all utilization reviews
- Appropriately refer members for further care engagement when needed
- Develop a working familiarity with applicable regulatory and accreditation requirements
- Participate in quality improvement activities as requested
- Clear written and spoken communication, including a poised phone presence
- Maintain continued active licensures, professional growth, and education to meet continuing education requirements and demonstrate knowledge & understanding of current nursing care practice
Required education and experience
- Active, unrestricted RN
- Willingness to obtain additional state licenses as needed for growth
- 2+ years utilization review experience at a managed care plan or provider organization
- Experience with MCG criteria
Preferred education and experience
- BSN
- Able to multi-task and manage tasks to completion on a timely basis and in an organized fashion
- Familiar with google platforms; willing and able to learn new software tools
- Able to work in a fast paced and evolving environment such as a startup