POST ACUTE RN REVIEW NURSE

About the position The Utilization Management Nurse plays a crucial role in the healthcare system by utilizing clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. This position requires a blend of clinical knowledge, communication skills, and independent critical thinking to interpret criteria, policies, and procedures effectively. The nurse will be responsible for providing the best and most appropriate treatment, care, or services for members, ensuring that they receive optimal care and treatment through effective coordination and communication with providers, members, and other parties involved in the healthcare process. In this role, the Utilization Management Nurse will make independent decisions regarding their work methods, often in ambiguous situations, and will require minimal direction while receiving guidance as needed. The nurse will follow established guidelines and procedures to ensure compliance and quality of care. Understanding the department, segment, and organizational strategy is essential, as well as recognizing the linkages to related areas within the healthcare system. This position is integral to the overall mission of the organization, which is focused on continuously improving consumer experiences and health outcomes. The Utilization Management Nurse will also be expected to rotate to Saturday coverage and may be required to work on holidays, reflecting the commitment to providing continuous care and support to members. This role is not only about clinical expertise but also about being part of a caring community that prioritizes health and well-being. Responsibilities • Utilize clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. , • Interpret criteria, policies, and procedures to provide appropriate treatment, care, or services for members. , • Coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment. , • Make independent decisions regarding work methods in ambiguous situations with minimal direction. , • Follow established guidelines and procedures to ensure compliance and quality of care. , • Understand department, segment, and organizational strategy and their linkages to related areas. Requirements • Bachelor's degree preferred. , • Must be a Licensed Registered Nurse (RN) in the appropriate state with no disciplinary action; compact state required, with ability to obtain noncompact state license. , • 4 - 5 years of clinical nursing experience required. , • Previous experience in utilization management preferred. , • Current clinical experience preferably in an acute care, skilled, or rehabilitation clinical setting. , • Comprehensive knowledge of Microsoft Word, Outlook, and Excel. , • Ability to work independently under general instructions and with a team. , • Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). , • Must be passionate about contributing to an organization focused on continuously improving consumer experiences. Nice-to-haves • BSN or Bachelor's degree in a related field. , • Health Plan experience. , • Previous Medicare/Medicaid experience a plus. , • Bilingual is a plus. Benefits • Medical, dental, and vision benefits. , • 401k with company matching. , • Tuition reimbursement. , • 3 weeks paid vacation time. , • Paid holidays. , • Work-life balance. , • Growth opportunities. , • Positive and fun culture. Apply Job!