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1030 UM Nurse

Grand Junction, Colorado
UM Nurse
Grand Junction, CO
The UM Nurse evaluates the appropriateness and necessity of medical treatment through the Utilization Management review process in order to promote quality, outcome-based medical care while providing world-class service to customers in an accurate, efficient and courteous manner.
 Duties and Responsibilities
  • The job holder will work with groups of Employees (EEs), and Functional Heads in addition to individuals across a variety of tasks:
  • Performs utilization management reviews in accordance with federal and state mandated regulations. Maintains compliance with regulatory changes affecting utilization management.
  • Perform UM reviews (prospective/concurrent/retrospective) for inpatient/ outpatient services according to the URAC standards and client requirements and/or policies.
  • Reviews UM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer.
  • Adheres to Department of Labor, state and company UM timeframe requirements
  • Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results
  • Tracks status of all utilization management reviews in progress
  • Releases UM determinations to claim stakeholders following client-established protocols.
  • Works closely with management team in the ongoing development and implementation of utilization management programs.
  • Certifies reviews that meet clinical review criteria/guidelines.
  • Adheres to quality standards and state UM guidelines
  • Maintains all required utilization management review documentation in the UM software in a timely manner.
  • Serves as first level contact for customer complaint resolution.
  • Responds to inbound telephone calls pertaining to UM reviews in a timely manner, following client-established protocols.
  • Processes customer calls consistent with program specified strategies and customer satisfaction measurements to include but not limited to proper answering procedure, e.g. opening and closing remarks.
  • Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
  • Maintains acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.
  • Learns new methods and services as the job requires
  • Advises supervisor of any potential problems as they become evident.
  • Manages assigned workload within established performance standards.
  • Attends meetings to achieve departmental goals and objectives.

Sudhanshu Karmalkar
Technical Recruiter
ReqRoute, Inc
Phone: 415-691-4708
Email: sudhanshu@reqroute.com

Companies across U.S. have engaged ReqRoute, Inc to deliver skilled, dedicated IT professionals. Recruiting is our passion and we support Fortune 1000 companies with their hiring needs. We always seek to deliver competitive and sought-after career opportunities to our potential consultants and employees. We invite you to review the position requirements and apply today if your skills match our needs.  
ReqRoute, Inc is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, disability, military status, national origin or any other characteristic protected under federal, state, or applicable local law. (www.reqroute.com)

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