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Utilization Management Nurse

Seattle, WA 98101 | Direct Hire

Job ID: 224324 Job Category: None Pay Rate: $85000.00/year
Are you a skilled Registered Nurse with a strong background of experience in a variety of different clinical settings? Do you have a passion for helping people, but maybe the physical strain of the clinical setting are starting to wear you down? Have you tried a couple clinical roles that turned out to be just not quite the right fit for you? Or maybe, you have been thinking about retiring but not sure you are really ready to stop working all together? If so, we want to talk to you!

Our Client is an AMAZING medical management company that is looking for a great Registered Nurse to join their awesome team! This role will require 50% your training period to be in Seattle, the other 50% of your time, as well as your day to day work. Will be remote/telecommuting from home! This is a great opportunity for someone that doesn t mind a possible longer commute to Seattle for their training, and then having an awesome commute from bed to their work area each morning!

Successful candidates will have a solid nursing background in a variety of different clinical settings or with displayed growth through their roles and responsibilities. Compassionate and empathetic communication skills will help you excel in the customer service functions of this role. Lastly, someone that is very computer savvy and can complete basic computer trouble shooting steps is strongly preferred, as this role is remote and work is computer based.

Benefits of working at this company are: Flexible telecommuting schedule; small & agile environment; stable company to provide excellent job security; and a competitive wage with an AWESOME benefits package!

Length of Assignment: Direct Hire
Compensation: $80, 000 - $90, 000 per year

Job Duties:
* Perform precertification reviews to establish medical necessity, appropriateness of services, and compliance with regulatory standards, established medical policy, community standards, and the member s plan documents.
* Perform concurrent and retrospective evaluation of inpatient hospitalizations to establish medical necessity, appropriateness of services, and discharge planning needs. Coordinates with the Medical Director to ensure clinically appropriate determinations.
* Identify and refers patients to case management, behavioral health, stop loss, subrogation, quality and external vendors for health and wellness services based on the appropriate guidelines and payor requirements.
* Apply clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines and accepted standards of care forwarding all cases that do not meet these policies and guidelines to the Medical Director.
* Identify and suggest alternative solutions including appropriate levels of care delivery or need for negotiations when indicated.
* Identify, investigate, and report to the Medical Director possible quality of care issues discovered during concurrent or precertification reviews.
* Participate in clinical rounds, quality improvement projects, continuing education, and Medical Management programs as required.
* Provide consistent and accurate case documentation using FCH applications.
* Create member correspondence using plain language and ensuring compliance with internal policies and procedures.
* Act as a liaison to members, participants, providers of care, and, when appropriate to payors

Job Requirements
* Registered Nurses License
* 3 years previous clinical experience
* UM/CM Experience in Hospital or Carrier Side
* Computer Savvy and strong data entry skills

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