Utilization Management Nurse
- Des Moines, IA
- $35.00-40.00 per hour
- Contract
- Full-time
- Conduct utilization management reviews and claims assessments using InterQual criteria and medical policy.
- Review medical records for suspended claims and provider inquiries to determine medical necessity.
- Collaborate with internal care management teams to meet member needs.
- Meet production metrics with a minimum of 40 reviews per day post-training and maintain a quality assurance standard of 97%.
- Document reviews accurately and consistently in Frontier and internal systems.
- Apply clinical criteria and benefit information to support medical review decisions.
- Ensure compliance with URAC, NCQA, HIPAA, and internal guidelines.
- Participate in cross-functional collaboration across divisions.
- Provide backup support to other UM teams, including precertification and continued stay reviews.
- Facilitate discharge planning and transition of care in collaboration with facilities and members.
- Perform other duties as assigned.
- Strong background in utilization management, utilization review, and medical policy.
- Proficiency in InterQual criteria and HIPAA regulations.
- Understanding of ICD and CPT coding systems.
- Completion of an accredited RN or LPN program.
- Active, unrestricted RN or LPN license in Iowa or South Dakota, with residency in the licensed state.
- At least 4 years of clinical experience in acute or outpatient settings.
- Familiarity with ICD9-CM, HCPC, CPT coding systems.
- Strong analytical and problem-solving skills.
- Excellent written and verbal communication.
- Attention to detail and ability to assess patient conditions via medical record review.
- Proficiency in electronic charting and Microsoft Office.
- Knowledge of URAC, NCQA, HIPAA, PHI standards.
- Ability to work independently and make decisions under ambiguity.
- Strong organizational skills and ability to manage multiple priorities.
- Collaborative mindset and professionalism in stakeholder interactions.
- Quick learner with strong technical acumen.
classification and length of employment. Benefits are subject to change and may be
subject to specific elections, plan, or program terms. If eligible, the benefits
available for this temporary role may include the following:
- Medical, dental & vision
- Critical Illness, Accident, and Hospital
- 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
- Life Insurance (Voluntary Life & AD&D for the employee and dependents)
- Short and long-term disability
- Health Spending Account (HSA)
- Transportation benefits
- Employee Assistance Program
- Time Off/Leave (PTO, Vacation or Sick Leave)