The Utilization Management (UM) Clinical Specialist RN for physical health (PH) independently assesses the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, and out of network services, monitors consumer treatment through ongoing and continuous review to ensure that services are delivered based on consumer need and established clinical guidelines, and identifies and follows-up on clinical cases of concern and high-risk/special needs consumers to ensure enrollees are linked to appropriate treatment resources. The UM Clinical Specialist RN - PH may represent the unit in cross agency collaborative needs.
This position will allow the successful candidate to work remotely, hybrid or on-site. There is a one weekend quarterly minimum requirement to ensure case compliance. Additional availability expected one major holiday and one minor holiday. The selected candidate must reside in North Carolina.
Responsibilities & Duties
Assesses the medical necessity of services
Independently conduct medical necessity reviews of service requests submitted by service providers against developed clinical guidelines within contractually mandated turn-around times
Ensure authorized services address appropriate service needs, intensity of service outcomes, and alternatives for consumers
Provide a consistent application of medical necessity criteria for physical health services that promotes a holistic review of the member’s needs
Conduct pre-certification, concurrent, and retrospective reviews to ensure compliance with medical policy, member eligibility, benefits, and contracts
Conduct utilization reviews to monitor adherence to clinical practice guidelines and best practice standards
Notify members of adverse benefit determinations while preserving members’ Due Process rights
Ensure compliance with performance measures outlined within all accrediting body standards
Perform other related duties as required by the immediate supervisor or other designated Alliance Health administrators
Compliance
Comply with utilization management and quality improvement policies and procedures, utilization review laws and regulations, state standards
Comply with Utilization Management Department focus on timeliness, effectiveness, quantity, quality, and cost of services for eligible enrollees
Coordinate and Implement UM Processes
Participate in the integration of the department and its functions into the organization’s primary mission
Take part in the Utilization Management Department collaboration to ensure an integrated department with Physical Health and Behavioral Health
Collaborate with other departments
Monitor for undesirable performance or deviations of practice standards that may have a negative impact on consumers.
Respond through additional follow-up with consumer and providers, provider technical assistance and/or referral to other departments within the MCO.
Maintain open, timely communication with staff, providers, community agencies and other stakeholders
Minimum Requirements
Education & Experience
Graduation from a State accredited school of nursing or an Associate’s Degree in Nursing from an accredited college/university and five years of nursing experience
OR
Bachelor’s degree in Nursing from an accredited college/university and three (3) years of nursing experience
Special Requirement-
Current, active, and unrestricted North Carolina clinical license as a Registered Nurse, or a compact license
Preferred Experience:
Experience in Utilization Management
Knowledge, Skills, & Abilities
Knowledge of physical health and co-morbid health conditions
Knowledge of diagnostic treatment guidelines/protocols, level of care criteria
Proficient in the use of computer and multiple software programs.
Written and oral communication skills
Ability to interact with a wide variety of individuals and handle complex and confidential sensitive situations.
Knowledge of Utilization Management managed care principles and strategies
Ability to analyze effectiveness of processes and adjust developed processes.
Knowledge of and experience in acute clinical utilization review
Knowledge of Authorization/re-authorization Utilization Management standards
Knowledge of related duties in the delivery of patient care, management of patient care providers, or project management in a healthcare environment
Ability to lead, delegate and problem solve
Ability to develop and document workflows
Ability to assist appeal efforts when medical care is denied by various payor entities in a timely fashion.
Knowledge of and experience with NCQA
Salary Range
$66,240 to $84,456/Annually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
Medical, Dental, Vision, Life, Long Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave
