Job Summary
A professional services firm specializing in IT, healthcare, and accounting needs applicants for an opening for a Telecommute Ohio RN licensed UM Nurse.
Candidates will be responsible for the following:
- Performing concurrent reviews of inpatient and inpatient sub-acute claims
- Performing prior authorization reviews for outpatient services
- Identifying solutions to problems and non-standard requests
Required Skills:
- Possession of current unencumbered RN license in Ohio (which is not a compact state)
- 5+ years of acute clinical experience and 2+ years of utilization management experience
- Demonstrated knowledge of and proficiency using Milliman Care Guidelines (MCG) and/ or InterQual criteria
- Experience in utilization management for Medicare Advantage, Managed Medicaid, Dual SNP, & Commercial Lines of Business
- Proven strong knowledge of utilization management processes, standards, and an understanding of managed care
- Detailed knowledge of and competency in all types of medical-necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, MLTSS, hospice care and home health care
