RN Utilization Management Specialist

Hybrid F/T RN Utilization Management Specialist Needed in Park Ridge, IL Our client, a growing Medicare Advantage Plans Ins. Co. located in Park Ridge; IL has an immediate need for an experienced partially remote, direct hire full-time IL Licensed RN UM Specialist. Hours for this position: M-F (8:30am-5:00pm) & one Sat/mo. 9am -1pm. We understand that you cannot submit any comments or text with your resume. If you apply through Monster, please send a separate email to cjepsen[at]managedcarestaffers.com with the answers to the following questions in order to be considered for this position: Are you an IL Licensed Registered Nurse? How many years of utilization review experience do you have? How many years of Milliman criteria experience do you have? What is your desired minimum hourly compensation? Do you have experience performing UM with Medicare Advantage Plans? Is Park Ridge, IL a good location for you? Job Responsibilities Performs prospective, initial, concurrent, and retrospective reviews for all requested services to include but not limited to the following: inpatient admissions, concurrent reviews, discharges, (DME), Part B drugs, & outpatient and home health services. Monitors level and quality of care of services being provided and approved. Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs. Under the supervision of the UM Team Lead and Medical Director, evaluates and provides feedback as needed to treating physicians regarding a member's discharge and home care plans, available covered services including identifying alternative levels of care that may be covered. Monitors the UM system to assure compliance with turnaround time frames. Coordinates an interdisciplinary approach to support continuity of care. Provides UM, transfer coordination, discharge planning, and issuance of all appropriate authorizations Responsible for the early identification and assessment of members for potential inclusion in a comprehensive care coordination program. Refers members for care coordination accordingly. Actively participates in the discussion and notification processes that result from the clinical utilization reviews with members or members’ representatives, facilities, requestors, and service providers. Prepares CMS-compliant notification letters of NON-certified and negotiated days and services within established time frames. Assists in the identification and reporting of Potential Quality of Care concerns. Job Qualifications Licensed Registered Nurse Experience in the application of Milliman criteria or other evidence-based medical criteria. 2 – 4 years utilization review and/or managed care experience is preferred. Knowledge of medical problems encountered with Seniors. Working knowledge of Medicare Advantage Plans. Strong computer skills – Microsoft Office Suite & communication and interpersonal skills. If you or anyone you know is interested, qualified and currently seeking employment please e-mail an updated resume to us for immediate review and consideration.