Utilization Review Nurse, RN (Oncology)

Role Summary:

The Utilization Review RN Case Manager shall work in a collaborative fashion to promote the provision of quality care and cost-effective outcomes that will enhance the physical, psychosocial, and vocational health of the plan participants in accordance with the policies and procedures of Lucent Health Care Management, LLC, URAC UM Standards, and the laws and established practices associated with medical management.

Daily role responsibilities:

The Utilization Review RN Case Manager shall be responsible for all aspects of the utilization review process as directed by the Supervisor of Utilization Review.

• Activities shall include, but not be limited to, inpatient and outpatient review, admission review, discharge planning, retrospective review, readmission review, large case management screening/identification, identification and communication of large claim potential, development, review, revision, and implementation of quality improvement programs and protocols (as directed by the Supervisor of Utilization Review), excellent coordination and communication of medical information with large case and disease management and payers (as appropriate), appropriate usage of physician advisors, adherence to URAC requirements and LHCM. documentation, quality, and productivity standards, completion of requests for attending physician statements, and customer service support.
• The Utilization Review RN Case Manager is responsible, on a daily basis, for completing the “tickler”, returning telephone and voice mail messages within established timeframes, accurately and adequately documenting all interactions, checking and responding to e-mail, faxes, and regular mail, interacting with all internal and external customers in a positive, proactive, and helpful manner, and providing any and all necessary support to the Supervisor of Utilization Review and the entire LHCM team.
• The UR Case Manager shall complete the LHCM Orientation and Training Course that includes policies and procedures and URAC UM Standards, be familiar and supervise the activities of the non-clinical administrative staff relative to the UR function, utilize telephones, access the server, or other software that may be provided by LHCM to perform daily duties, and be familiar with the Clinical Review Guidelines.
• The UR Case Manager shall be responsible for providing all aspects of excellent customer service and development, maintaining confidentiality, completing an orientation and participating in an ongoing training program which includes policies and procedures, URAC UM Standards, and clinical review guidelines.
• The UR case manager only certifies care or services. If the care or service requested is not meeting initial clinical review criteria, then the case is referred to a peer clinical reviewer.

This position could be a good fit if you have:

• Registered Nurse with a minimum of 5 years of recent clinical nursing experience
• Bachelor’s Degree and/or Certification in UR, Case Management, or a related field-preferred
• Excellent Written and Oral Communication
• Positive, proactive team-oriented approach/attitude
• Excellent Computer skills
• Holds an active, unrestricted RN license that allows him/her to practice in a state or territory of the United States.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

• Work hours 9am-6pm EST Monday-Friday
• Remote – Work from home
• One late day per month 10am-7pm EST
• Occasional compensated on-call from home
• Holidays required 2 shifts per year with holiday pay
• Oncology experience is preferred.
• Required in person training at our downtown Nashville location for one week.

Physical and Emotional Demands:

While performing the duties of this job, the employee is frequently required to sit. The employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; climb or balance; stoop, kneel, and talk or hear. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus.

Salary: $75,000 - $79,000/yr

Equal Employment Opportunity Policy Statement
Lucent Health Solutions, Inc. is an Equal Opportunity Employer.