Utilization Management - Rn/Lpn - Full Remote (Contract-To-Perm $44/Hr)

Job Title:Utilization Management Registered Nurse (RN) - Inpatient and Outpatient Reviews
Job Description: We are seeking two Nebraska licensed Registered Nurses (RNs) for Inpatient Reviews and two Nebraska licensed RNs for Outpatient Reviews. In this role, you will review inpatient and outpatient services for members to ensure optimal outcomes, cost-effectiveness, and compliance with all state and federal regulations and guidelines.
Must-Have Skills:

• Utilization Management (UM) experience
• Managed Care Organization (MCO) experience for inpatient (IP) or outpatient (OP)
• Strong computer skills
• Familiarity with InterQual (IQ) or Milliman Care Guidelines (MCG)
• Medical experience
• Willingness to work collaboratively as part of a team

Day-to-Day Responsibilities:

• Reviewing authorizations with criteria from state sites, clinical policies, or guidelines like MCG.
• Applying guidelines for decision-making and consulting the medical director when necessary.
• Reviewing medical records to complete reviews in a timely manner.
• Assisting in authorization building as needed.

Required Years of Experience:

• 3+ years of hospital acute care/medical experience
• UM experience

Required Licensure/Education:

• Active, unrestricted Nebraska State registered nursing license (RN) in good standing

Schedule: Monday to Friday, 8:00 AM to 5:00 PM CST
Summary: Join our Utilization Management team responsible for inpatient medical necessity/utilization review and other activities at a Managed Care Organization (MCO). Ensure that members receive the right care at the right place and time. Review and evaluate members requiring hospitalization or procedures, providing prior authorizations and concurrent reviews. Assess services for optimum outcomes, cost-effectiveness, and compliance with regulations.
Essential Functions:

• Provide concurrent review and prior authorizations as needed for MCO members.
• Determine appropriate benefits, eligibility, and expected length of stay for treatment requests.
• Collaborate with various departments to enhance continuity of care for members.
• Maintain department productivity and quality standards.
• Attend regular staff meetings and mentor new team members.
• Complete work plan objectives and projects on time.
• Build and maintain professional relationships with providers and stakeholders.
• Consult and refer cases to medical directors as necessary.
• Comply with workplace safety standards.

Knowledge/Skills/Abilities:

• Strong communication, problem-solving, and interpersonal skills.
• Excellent organizational abilities with multitasking capabilities.
• Proficiency in InterQual and other length of stay and medical necessity references.
• Familiarity with NCQA and relevant regulations.
• Initiative, follow-through, and ability to work independently.
• Computer literacy (Microsoft Office).
• Strong verbal and written communication skills.
• Adherence to company policies and confidentiality.
• Positive work relationships with colleagues, clients, members, providers, and customers.

Required Education: Completion of an accredited Registered Nursing program (a combination of experience and education considered).
Required Experience: Minimum 2-4 years of clinical practice, preferably in hospital nursing, Utilization Management, or case management.
Required Licensure/Certification: Nebraska Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.