OP Utilization Review RN

REPORTS TO: UM Supervisor LOCATION: Allegiance Office or Offsite FSLA STATUS: Exempt The Utilization Review RN is responsible for promoting the quality and cost-effectiveness of medical service and admission reviews by applying clinical judgement in accordance with medical policies and national guidelines to determine authorization/certification of said service/admission.
The UM RN ensures that all reviews are completed in a timely fashion to meet contractual requirements.
This position may also include participating in team functions such as committees, QA team evaluations, and preceptorships.
The incumbent is expected to conduct all communication and assignments professionally with peers, supervisors, subordinates, vendors, customers, and the public.
ESSENTIAL JOB FUNCTIONS: Essential job functions include the following.
Other functions may be assigned as business conditions change.
 Conducts reviews, facilitates planning referrals, and screens for and initiates referrals for Case Management.
 Identifies and refers cases NOT meeting criteria and coordinates appeals and denials with Medical Directors.
 Maintains an intimate working knowledge of clinical guidelines (ASAM, MCG, URAC), clinical decisions support tools, Cigna medical policies and effective usage of care management documentation systems.
 Provides services within the scope of practice defined by current education, certification or licensure, community and published standards.
 Assist Senior Management with special requests that pertain to team.
 Responsible for maintaining confidentiality standards, as mandated by HIPAA.
 Organizes personal workload and contributes time and effort to the team workload by: Ensuring that phone calls are returned by the next business day.
Completing all reviews and reporting in a timely manner.
Maintaining a thorough knowledge of and compliance with policies, procedures, and Quality Assurance requirements.
Attending and/or participating in the majority of staff/team meetings.
Identifying, evaluating, and providing feedback on departmental workflows to increase efficiency.
Participates in orientation and training of new employees.
Perform other duties and job functions as assigned.
Preparation of forms, faxing, copying.
Organization of files and reference materials.
Ability to operate typical office equipment and working knowledge of basic office practices.
Contributes to the daily workflow with regular and punctual attendance.
NON-ESSENTIAL JOB FUNCTIONS:  Performs related or other assigned duties as required or directed.
PHYSICAL WORKING CONDITIONS: Physical requirements are representative of those that must be met to successfully perform the essential functions of this position.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Sitting 80% Reaching Minimal Standing 10% Manual Dexterity Ability to type/keyboard Walking 10% Telephone High Degree Kneeling Minimal Computer Screen High Degree Bending Minimal Lifting 25 pounds JOB SPECIFICATIONS: To perform this position successfully, an individual must be able to perform each essential duty satisfactorily.
The requirements listed below are representative of the knowledge, skill and/or ability required.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions Licensure/Education/Experience: Licensed RN (ASN or BSN), and three (3) years clinical practice experience.
Insurance/Managed Care Experience Preferred: Understand the complex nature of regulatory requirements as they relate to medical necessity versus provider requests.
Other Experience:  Must possess organizational skills and the ability to prioritize multiple tasks, attention to detail and follow through to completion.
 Excellent oral and written communication skills required.
 PC skills, including Windows and Word.
Ability to learn all functions of the claims processing software as is necessary for claims processing and adjudication.
Must be able to adapt to software changes as they occur.
 Excellent listening skills.
 High level of interpersonal skills to work effectively with others.
 Ability to organize and recall large amounts of detailed information.
 Ability to read, analyze and interpret benefit summary plan descriptions, insurance documents, plan benefits, and regulations and make appropriate applications to specific situations.
 Thorough knowledge of claims processing procedures and requirements.
 Ability to project a professional image and positive attitude in any work environment.
 Ability to comply with privacy and confidentiality standards.
 Ability to be flexible, work under pressure and meet deadlines.
 Ability to analyze and solve problems with professionalism and patience, and to exercise good judgment when making decisions.
 Ability to operate typical office equipment.
 Working knowledge of general office procedures.
The above statements are intended to describe the general nature and level of work being performed.
They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel as classified.
By signing this statement, the employee understands the scope of their licensure and will practice within the scope of that licensure.
If the status of the licensure/certification changes, the employee will notify the department supervisor of the change immediately.
The employee understands that failure to maintain current licensure and/or to practice within the scope of that licensure, as well as failure to report any changes in license status, will result in disciplinary action, up to and including termination.
*Allegiance Benefit Plan Management, INC is an Equal Opportunity Employer.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you require reasonable accommodation in completing the online application process, please email: recruiting@askallegiance.
com for support.