The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
- Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action. Must have license in Puerto Rico -and- in Florida or compact state license.
- Previous experience in utilization management required
- 3+ years clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
- Comprehensive knowledge of Microsoft Word, Outlook and Excel
- Ability to work independently under general instructions and with a team
- Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10×1 (10mbs download x 1mbs upload) is required
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
- 3 or more years experience in a high volume community or mail order pharmacy practice environment
- Education: BSN or Bachelor’s degree in a related field
- Health Plan experience
- Previous Medicare/Medicaid Experience a plus
- Call center or triage experience
- Bilingual is a plus
Scheduled Weekly Hours