Job Description

The Offer

• Fantastic work culture

The Job

Key Responsibilities

• Conduct prior authorization, concurrent, and retrospective reviews for various healthcare services, including inpatient, outpatient, home health, and behavioral health.
• Apply evidence-based criteria (e.g., MCG, InterQual) to assess the necessity of medical services.
• Collaborate with healthcare providers, medical directors, and clinical staff to facilitate appropriate care plans and resource utilization.
• Maintain accurate and organized documentation of all utilization management activities.
• Participate in quality improvement initiatives and assist in developing clinical guidelines.
• Monitor and report on utilization trends to management, identifying areas for improvement. 

The Profile

Qualifications

• Bachelor's Degree in Nursing (BSc Nursing) or equivalent.
• Minimum of 2 years of clinical experience in a hospital or healthcare setting.
• Active and unrestricted Registered Nurse (RN) license in the United States.
• Familiarity with utilization management processes and guidelines (e.g., MCG, InterQual).
• Proficient in medical terminology, anatomy, and physiology.
• Strong analytical and problem-solving skills.
• Excellent communication skills, both written and verbal.
• Proficient in Microsoft Office applications. 

Preferred Qualifications

• Experience with Medicaid, Medicare, and Managed Care programs.
• Previous experience in utilization review or case management.
• Certification in Case Management (CCM) or Accredited Case Manager (ACM) is a plus.

The Employer

Our client specializes in Healthplan IT solutions, offering a comprehensive suite of services designed to enhance efficiency and improve digital presence for health plans and Third-Party Administrators (TPAs).

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