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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 is full-time remote. Selected candidate must reside in North Carolina and be willing to travel to one of the offices for business or onsite team meetings as needed.

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 and five years of experience with five (5) years 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 

$69,592-$88,729/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
• Dress flexibility