Job Title: Utilization Management NurseJob Description
We are seeking a dedicated and detail-oriented Utilization Management Nurse to join our team. The ideal candidate will be responsible for meeting all State and Federal regulations, as well as internal mandates related to claims and preauthorization processing. This role involves accurate and timely medical review of claims, preauthorizations, and customer service inquiries. You will also be involved in special projects such as training new hires, provider outreach, project work, peer mentoring, new system implementation, and system testing.
Responsibilities
+ Ensure compliance with State and Federal regulations, as well as internal mandates for claims and preauthorization processing.
+ Perform accurate and timely medical reviews of claims and preauthorizations.
+ Handle customer service inquiries related to claims and preauthorizations.
+ Complete special projects, including training new hires, provider outreach, project work, peer mentoring, new system implementation, and system testing.
+ Determine availability of benefits according to company contracts, endorsements, and medical policy.
+ Verify member eligibility prior to medical review.
+ Foster constructive relationships with all departments.
+ Maintain professional licensure and practice within the scope of licensure.
+ Collaborate and consult with healthcare providers, members, and an internal team of clinical support specialists, nurses, physicians, medical directors, and pharmacists to ensure medically appropriate, high-quality, cost-effective care.
Essential Skills
+ Current, unrestricted RN license or a compact license from specified states.
+ Three years of clinical experience in a healthcare setting.
+ Two years of experience in medical review or utilization management.
+ Knowledge of utilization review, Medicare, utilization management, and EMR systems.
Additional Skills & Qualifications
+ Bachelor's degree in a healthcare field (preferred).
+ Certification in managed care (preferred).
+ Clinical experience in multiple levels of care.
+ Knowledge of accreditation standards and regulatory requirements.
+ Experience with Guiding Core, InterQual, and MCG EMR systems.
+ Experience in acute care, post-acute care, and outpatient care is a plus.
Work Environment
This is a 100% remote position. The company will provide a laptop, two monitors, a mouse, keyboard, and headset. The core shift is Monday to Friday, 7 am to 5 pm CST, but there are options for flexible shifts, including Tuesday to Saturday or Sunday to Thursday. Weekend-only part-time positions are also available.
About Actalent
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
Diversity, Equity & Inclusion
At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:
+ Hiring diverse talent
+ Maintaining an inclusive environment through persistent self-reflection
+ Building a culture of care, engagement, and recognition with clear outcomes
+ Ensuring growth opportunities for our people
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email [email protected] (%[email protected]) for other accommodation options.
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