RN Utilization Management Nurse

Salary: Pays up to $39/hr ($2,000 sign on bonus) with great benefits package

Shift: Monday to Friday 8:00AM to 5:00PM

• Performs review of requested outpatient and elective, prospective inpatient medical services. • Under the direction of the UM Clinical Supervisor coordinates and refers KHS members for services which are carved out of KHS medical coverage. • Assists in the authorization and processing of automatic referral requests. • Responsible for written and verbal communication with contract providers and internal KHS staff to promote timely coordination of care and dissemination of KHS policies and procedures. • Collaborates with the KHS Member Service Department and the Provider Relations Department regarding quality of care and other grievance issues in order to facilitate timely problem resolutions. • Utilizes Milliman and Medicaid criteria to review DME, home care, rehab and SNF referrals for medical necessity and benefit coverage while processing referral request. • Identifies and refers quality of care, coordination of benefits, and third party liability issues as appropriate. • Maintains knowledge of covered benefits for all programs. • Shares information as necessary with appropriate Case Manager, Disease Management Nurse, or Social Worker. • Identifies and refers cases appropriate for Case Management evaluation. • Identifies authorization issues and brings those requiring attention to the UM Supervisor.