UM Nurse Specialist
Corizon Health
- Brentwood, TN
- Permanent
- Full-time
- Experience Level: 3 - 5 year’s experience in utilization management, case management, quality management. Experience with InterQual and/or Milliman Care guidelines preferred. Strong organizational and time management skills.
- Tools and Technology: Computer usage for word processing, spreadsheets, email, internet, medical records and other proprietary company/client systems.
- Certificates and Licenses: Registered Nurse (RN) active license
- Language Ability: Strong verbal, written communication skills. Effectively present information in one-on-one and group situations to nursing staff, clients and other employees of the organization.
- Reasoning Ability: Ability to work on extremely complex problems where analysis of situations or data requires an evaluation of intangible variance factors.
- Work Environment: Office environment with occasional travel up to 10% to regional offices, client and/or vendor sites.
- Responsible for the implementation of a comprehensive outpatient/inpatient review process utilizing criteria based review standards and standards of best practice.
- Facilitate quality health care intervention recommendations.
- Review and assess over/under utilization issues.
- Track, trend and evaluate appropriateness and quality of care issues with the implementation of education to internal and external customers and process improvement initiatives.
- Respond to inquiries by provider/site employees relating to standards of care and best practices.
- Develop and maintain pre-established review parameters under the direction of the YesCare Medical Director.
- Identify and document comparisons with community standards, regionally based as indicated.
- Communicate and guide staff and physicians regarding utilization management program development, implementation, evaluation and reporting.
- Work with other UM inpatient and outpatient nurse reviewers to assure proper treatment in the appropriate setting at the appropriate time.
- Communicate and document any issues relating to the outpatient/inpatient UM process to the Manager of Utilization Management.
- Assist with the data collection and reporting related to the UM outpatient/inpatient process.
- Participate in CEU offerings/seminars to enhance professional growth and development and the maintenance of nursing license.
- Recommend improvements to process and outcomes using data analysis tools, logical rules/relations and data elements.
- Performs miscellaneous job-related duties as assigned.
- Health, Dental and Vision Insurance
- Life and Disability Insurance
- Generous PTO plan
- 401k with matching funds
- Employee Discount and Rewards Program
- Tuition Assistance
- Continuing Education Reimbursement