Utilization Management Nurse

Position Overview

The Utilization Review Nurse is responsible for coordinating all components of the utilization review process, which includes timely review of treatment requests for medical necessity, ensuring appropriate cost-effective treatment and promotion of best patient outcomes. The Utilization Review Nurse performs the initial clinical review, prepares an organized case summary and may issue certifications of medical necessity. When clinical requirements for medical necessity, appropriateness or effectiveness are not met and a clinical determination to certify the request cannot be made, the Utilization Review Nurse must escalate the case for peer clinical review. The Utilization Review Nurse provides clinical oversight and serves as a resource for non-clinical staff.

Roles and Responsibilities

• Coordinates the utilization review process for each treatment request.
• Provides clinical oversight and serves as a resource for non-clinical staff.
• Conducts initial clinical review for medical necessity against approved evidence-based guidelines.
• Evaluates need for continued or alternative treatment with provider.
• Discusses treatment options with requesting provider.
• Documents utilization review components within the Ethos Utilization Management System per State, Federal and URAC requirements, including data collection for analysis and trending.
• Refers, coordinates and interacts with peer clinical reviewers.
• Facilitates peer discussion during peer clinical review process.
• Partners with medical providers to promote best patient outcomes.
• Adheres to Ethos Policies and Procedures and URAC standards as appropriate to job functions.
• Assists in promoting and furthering the objectives of the Quality Management Program.
• Maintains confidentiality and security in all aspects of performance.
• Performs other related duties incidental to the work described herein.

Qualifications

Education/Licensure/Certification

• Completion of formal training in a health care field; and
• Active, unrestricted professional license or certification to practice as a health professional in a state or territory of the United States:

1. An associate degree or higher in a health care field (RN); OR
2. State license or state certificate in a health care field (LVN/LPN).

• Certified Case Manager (CCM), Health Care Quality & Management (HCQM) or equivalent certification preferred.

Experience

• 2 years of clinical nursing experience (direct patient care, administrative or combination post licensure).
• 1-year experience with workers' compensation/utilization management preferred.

Skills/Knowledge

• Knowledge of workers' compensation laws and regulations (preferred).
• Discretion and confidentiality.
• Good customer service skills.
• Strong oral and written communication skills.
• Computer knowledge required, including Microsoft Office products.
• Able to perform as part of a team.
• Analytical and interpretive skills.
• Strong organizational skills.
• Excellent interpersonal skills.
• Good negotiation skills.
• Ability to multi-task.

Ethos Risk Services is an equal opportunity employer that does not discriminate on the basis of religious creed, sex, national origin, race, veteran status, disability, age, marital status, color or sexual orientation or any other characteristic protected by law.

A background check will be conducted, in accordance to the local state law and regulations.