Entry Level Utilization Management Nurse Jobs (NOW HIRING)

MISSION
Our mission is to enhance well-being by connecting individuals with vital health resources through a compassionate workforce that embodies the spirit of neighbors helping neighbors.

VALUES
HealthOne is guided by a cultural framework that embodies our values and drives our decisions.

Our PURPOSE is to care for people by connecting them to resources that help protect them in health related situations. To fulfill our purpose, we align our PRIORITIES to ensure each decision we make is ethical, empathetic, economical, and efficient. We care for PEOPLE by being welcoming, authentic, truthful, consistent, and humble. We are continuously looking for ways to improve our PROCESS and how we get things done.

HealthOne seeks individuals with integrity and heart to embody our values. Whether you're starting your career or looking to develop additional skills to reach your full potential, HealthOne provides the means to help you achieve your goals.

JOB PURPOSE
The UM Nurse Team Lead ensures efficient, cost effective, and high quality delivery of utilization review service by supporting and training a staff of registered nurses; to oversee the management of medical cases worked by registered nurses; to oversee individual and overall results/outcomes of all cases within their scope of responsibilities; and to ensure customer satisfaction through the provision of cost effective and high quality utilization review service that meets their needs.

ESSENTIAL JOB DUTIES
Serve as a clinical and operational team lead for Utilization Management nurses, providing day to day guidance, mentorship, and clinical support
Act as an escalation resource for complex utilization reviews, appeals, and provider/member issues requiring advanced clinical judgment
Trains and develops utilization review staff
Works with Utilization Management Manager to establish and ensure achievement of completion of prior authorization reviews, productivity, and quality goals
Initiate referrals to ensure appropriate coordination of care
Seek the advice of the Medical Director when appropriate, according to policy
Assists non-clinical staff in performance of administrative reviews
Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility
Maintains regular and predictable attendance
Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
Works to encourage and promote Company culture throughout the organization
Other duties as may be assigned

QUALIFICATIONS
3 years Clinical experience preferred
2 years of Utilization Review
Proficient in Microsoft Office (Outlook, Word, Excel)
Working knowledge of NCQA preferred
Must be able to work in an independent and creative manner
Ability to manage multiple projects and priorities
Adaptive to high pace and changing environment
Customer service oriented
Proficient in interpreting benefits, contract language and medical policy/medical review criteria
Current, active Compact State license in Nursing (RN)

PHYSICAL REQUIREMENTS
Prolonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required.

BENEFITS
401K (4% Match, Immediate Vesting)
Accident insurance
Competitive salary
Critical Illness Insurance
Dental Insurance
Employee Assistance Program
Flexible Spending Account
Health & Wellness Program
Health Savings Account
Life & AD&D Insurance
Long Term Disability
Medical Insurance
Paid Time Off
Pet Insurance
Short Term Disability
Vision Insurance

PRE-EMPLOYMENT SCREENING
Drug Screen and Background Check Required

HEALTHONE IS AN EQUAL OPPORTUNITY EMPLOYER
All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status, or any other status protected by state or federal law.