UM Review Nurse 8/17/2016
JOB DESCRIPTIONAPPLY POSITION TITLE: UM Review Nurse (RN)
WORK LOCATION: Tampa, FL
CLIENT : Cognizant
The UM Review nurse assesses the medical necessity and quality of healthcare services by conducting the following types of requests: pre service, concurrent, and retrospective utilization management reviews.
ROLES AND RESPONSIBILITIES
Assesses the medical necessity, quality of care, level of care and appropriateness of health care services for plan members.
Conducts outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data.
Applies clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided.
Certifies cases that meet clinical review criteria, guidelines and/or screens.
Consults with physician when reviews do not meet clinical review criteria, guidelines, and screens.
Refers cases to other professionals internally, including case management and medical consultation when indicated.
Ensures the integrity and high quality of utilization management services.
Adheres to accreditation, contractual and regulatory timeframes in performing all utilization management review processes.
Strictly follows company policies related to the handling, release and disposal of confidential information.
Ensures that the Operations Manager or designee is made aware of any potential risk management issues in a timely manner.
Consistently meets medical management standards for attendance and punctuality.
At all times treats others with dignity and respect.
May require occasional overnight travel, particularly for training.
EDUCATION AND LICENSURE:
Education leading to the completion of an approved RN program
Current, active and unrestricted US RN license. Florida RN license preferred but will consider other states.
At least 1 year experience in utilization management with a health plan or hospital based UM dept. with use of Interqual or MCG.
Prefer at least 3-4 years of clinical experience
Current CCM credential is a plus
Self-motivated and able to work under pressure.
Ability to effectively manage multiple shifting priorities.
Able to meet deadlines.
Thrives in a team environment.
Must be able to work congenially with a wide variety of individuals.
Must be able to maintain the highest level of confidentiality and professionalism at all times.
Must have strong oral and written communications skills.
Must be proficient in navigating through multiple computer applications.
Cognizant (NASDAQ: CTSH) is a leading provider of information technology, consulting, and business process outsourcing services, dedicated to helping the world's leading companies build stronger businesses. Headquartered in Teaneck, New Jersey (U.S.), Cognizant combines a passion for client satisfaction, technology innovation, deep industry and business process expertise, and a global, collaborative workforce that embodies the future of work. With over 100 development and delivery centers worldwide and approximately 219,300 employees as of September 30, 2015, Cognizant is a member of the NASDAQ-100, the S&P 500, the Forbes Global 2, and the Fortune 500 and is ranked among the top performing and fastest growing companies in the world. Visit online at www.cognizant.com or follow on Twitter: Cognizant.
Next Level Business Services, Inc.
Phone: +1 (904) 240-4185 | Fax: +1 (608)646-8326
Web:www.nlbservices.com | linkedin - bhaskar-mahaseth