Utilization Management RN III

Responsibilities: The role involves reviewing and documenting prior authorization requests and member case histories to determine coverage approval. Additionally, the nurse analyzes trends to recommend revisions to medical policies and utilization management procedures.

Requirements: Candidates must possess an active, unrestricted RN or LPN license and a bachelor's degree or equivalent experience. A minimum of 5 years of work experience beyond the degree is required.

Key skills: Utilization Management, Clinical Judgment, Prior Authorization, Clinical Assessment, Critical Thinking, Evidence-Based Decision Making, Case History Documentation, Regulatory Compliance, Organization Skills, Technology Proficiency

Keywords: Utilization Management, RN License, LPN License, CMS, NCQA, Prior Authorization, Clinical Appeals, Medical Policies, Healthcare, Case Management, Utilization Review