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Utilization Manager (UM) Review Nurse

Company: Tennessee Health Management
Location: Franklin
Posted on: December 3, 2018

Job Description:

Apply Now Utilization Manager (UM) Review Nurse Franklin, TN, USA Req #806 Monday, November 19, 2018 The purpose of this position is to assess the medical necessity and quality of healthcare services by conducting the following types of requests: pre-service, concurrent, and retrospective utilization management reviews. The primary role of the Utilization Management (UM) Nurse is to provide clinical support to the Clinical Services Department and Medical Director to assure that members receive all appropriate medical services in compliance with medical and regulatory guidelines. Description of Required Duties and Tasks: Assess the medical necessity, quality of care, level of care and appropriateness of health care services for plan members. Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity. Conduct outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data. Apply clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided. Certify cases that meet clinical review criteria, guidelines and/or screens. Consult with physician when reviews do not meet clinical review criteria, guidelines, and screens. Refer cases to other professionals internally, including case management and medical consultation when indicated. Develop and maintain collaborative relationships with providers and educate on levels of care. Ensure the integrity and high quality of utilization management services. Adhere to accreditation, contractual and regulatory timeframes in performing all utilization management review processes. Ensure that the Director of Medical Management or designee is made aware of any potential risk management issues in a timely manner. Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility. Encourage an atmosphere of optimism, warmth and interest in patients' personal and health care needs.

Required Work Experience: At least 1-year experience in utilization management with a health plan or hospital-based UM dept. with use of Interqual or MCG. Prefer clinical experience. Current Certified Case Manager (CCM) credential is a plus Broad knowledge of Medicare regulations and guidance. Trained in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures. Excellent customer service experience. Strong knowledge of medical terminology and CPT, ICD-10, and HCPCS codes. Proven ability to problem-solve and make solid decisions. Qualifying criminal background. American Health Management Services is an Equal Opportunity Employer

Keywords: Tennessee Health Management, Franklin , Utilization Manager (UM) Review Nurse, Executive , Franklin, Tennessee

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