The Utilization Management Nurse performs clinical review of prior authorizations, network exceptions, benefit inquiries, inpatient medical/surgical admissions, and outpatient procedures. This role evaluates the efficiency and appropriateness of services for medical necessity using evidence-based criteria, clinical and corporate guidelines, policies, and standards, while promoting appropriate, high-quality, and cost-effective care.
Responsibilities
Work incoming and outbound calls and queues from multiple sources within mandated requirements proactively and effectively.
Conduct and monitor clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgeries.
Document all relevant and specific information and organize determination requests according to mandates and standards.
Practice nursing within the scope of licensure and adhere to policies, procedures, regulations, accreditation standards, and state regulations.
Make determinations based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.
Remain current on medical and surgical procedures, products, healthcare services and drugs, and general trends in healthcare delivery.
Maintain current knowledge of enterprise procedures, policies, and contracts relevant to utilization management.
Collaborate with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility, and appropriate service levels.
Promote appropriate care and quality toward cost-effective and cost-containment measures based on evidence.
Perform other related duties as assigned.
Requirements
Registered Nurse (RN) with an active, unrestricted license in good standing in the applicable jurisdiction.
Minimum of four (4) years of clinical nursing experience in at least one of the following areas: medical-surgical, surgical, intensive care, or critical care.
Bachelor s degree in Nursing preferred.
Experience in utilization management and/or medical review preferred.
Ability to prioritize and make sound nursing judgments using critical thinking.
Ability to interpret complex clinical documentation.
Ability to work independently and build collaborative relationships.
Proficiency with basic computer skills and Microsoft Office applications, including Word, Excel, Outlook, and the ability to navigate multiple systems.
Summary Qualification
Licensed Registered Nurse with strong clinical background in acute or critical care settings.
Demonstrated experience in care management, utilization review, or related medical review functions.
Proven ability to apply evidence-based criteria and clinical guidelines to determine medical necessity.
Skilled in documentation, organization, and managing multiple concurrent cases.
Committed to patient safety, quality of care, and cost-effective resource utilization.
Skill
Sound judgment and critical thinking
Analytical decision making and problem sensitivity
Data analysis and attention to detail
Oral and written communication
Active listening and interpersonal relationship management
Time management and ability to manage competing priorities
Proficiency with Microsoft Word, Outlook, and SharePoint
Ability to build collaborative relationships and work independently
Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.
Numbers & Facts
Location
Little Rock, AR
Skills
Accreditation Standardsunmatched
Analysis Skillsunmatched
Clinical Monitoringunmatched
Clinical Nursingunmatched
Clinical Practices/Protocolsunmatched
Clinical Study Publicationsunmatched
Computer Skillsunmatched
Corporate Policiesunmatched
Cost Controlunmatched
Cost Effectiveness Analysisunmatched
Critical Careunmatched
Data Analysisunmatched
Detail Orientedunmatched
Documentationunmatched
Establish Prioritiesunmatched
Healthcareunmatched
Healthcare Providersunmatched
Interpersonal Skillsunmatched
Legalunmatched
Maintain Complianceunmatched
Medical Treatmentunmatched
Microsoft Excelunmatched
Microsoft Officeunmatched
Microsoft Outlookunmatched
Microsoft SharePointunmatched
Microsoft Wordunmatched
Nursingunmatched
Outpatient Careunmatched
Patient Careunmatched
Patient Care Authorizationsunmatched
Patient Safetyunmatched
Presentation/Verbal Skillsunmatched
Quality of Careunmatched
Registered Nurse (RN)unmatched
Regulationsunmatched
Relationship Managementunmatched
Resource Utilizationunmatched
Sales Managementunmatched
State Laws and Regulationsunmatched
Surgical Proceduresunmatched
Surgical Suppliesunmatched
Surgical intensive Care Unit (SICU)unmatched
Team Playerunmatched
Time Managementunmatched
Utilization Managementunmatched
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