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.

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.