Clinical Utilization Management Nurse Reviewer
Medica - Minnetonka, MN

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12202

Overview

The Clinical Utilization Management Nurse Reviewer works within the framework of Medica’s multiple products to establish collaborative processes that promote quality and cost effective care. This role researches and documents case history in compliance with policies and procedures for items contained within Medica’s prior authorization list. The role requires attention to detail and use of clinical judgment to determine clinical benefits. It also requires interfacing with members, providers, clinics, medical directors, intake staff, case managers and other departments within Medica.

In addition, it is responsible for the analysis of trends, which may be identified through the review of cases, and for addressing these issues by recommending review of medical and utilization management and/or clinical appeals policies. This person supports the development, planning and implementation of departmental and cross-departmental projects designed to improve operations and promote excellence.

Key Accountabilities:
Process Initiation and Evaluation

Communication

Projects/Team Accountabilities

Data Systems

Policy and Procedures

Qualifications

Bachelor's Degree,BSN or BS/BA preferred

3+ years related experience

Specific types of experience required:
Managed care experience preferred

Previous utilization management experience and/or clinical/hospital experience

Required Certifications/Licensure:
Valid, unrestricted RN license

Skills and Abilities:
Medical knowledge and background

Critical thinking skills

Ability to organize and present case in logical, sequential order

Attention to detail and accuracy

Flexibility in managing changes in job duties and work environment

Excellent written and verbal communications skills

Innovative problem solving skills

Able to focus on a variety of issues at one time

Relates well to internal and external customers

Demonstrates ability to use Microsoft Office suite

Strong customer service skills

Ability to think creatively, negotiate and access appropriate resources

Medica - 23 months ago - save job - block
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