Senior Utilization Management Nurse

Details:
Under minimal supervision, provides medical and/or behavioral health utilization management for members of Medical Plan in accordance with the schedule of benefits and network criteria defined by the Plan’s various lines of business and Center of Medicare & Medicaid Services (“CMS”) regulatory requirements. Completes clinical review to determine whether a request can be approved using nationally recognized criteria such as InterQual or MCG, or requires additional review by the Plan’s Medical Director.

MINIMUM QUALIFICATIONS:

Education:
Bachelor’s degree in Nursing. A combination of education and experience may be substituted for the B.S.N. requirement.

Experience:
Typically, three years of medical utilization management experience working with a health insurance plan, hospital, skilled nursing facility, or surgical center. Managed Care experience is highly preferred.