UR/Precert RN

Job Description:

$60K-$65K DOE

The Utilization Review/Precertification Registered Nurse utilizes clinical experience and medical guidelines in a collaborative process to assess, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Coordinates medical services requests from providers and determines medical necessity using internal guidelines, nursing judgment and the specific requirements of the member’s health plan.

Key Result Areas

• Conducts telephonic utilization review/precertification services including, prospective, concurrent and retrospective review utilizing clinical criteria guidelines, nursing judgment and physician advisor review as needed.
• Determines medical necessity and appropriateness of requested inpatient and outpatient services through review of clinical information and application of the appropriate clinical criteria guidelines.
• Assesses the member's current status, future care needs and treatment plan.
• Communicates with providers and other departments to facilitate care, transitions of care, and discharge planning.
• Identifies solutions to non-standard requests and problems.
• Identifies members for referral opportunities to integrate with other services (i.e. Case Management, Disease Management).
• Works closely with providers to ensure appropriate utilization of services and effective cost management.
• Maintains appropriate documentation and records cost management.
• Maintains confidentiality of records and information.
• Maintains and reports applicable statistics regarding programs and patient services.
• Attends weekly Leadership Forum/Company View, on-site team meetings and monthly staff meetings.
• Performs all duties within the scope of her/his license.
• Performs other duties as assigned or needed.

Experience and Skills:

* Current unrestricted Idaho R.N. license

• Associates Degree in Nursing (Bachelor Degree is a plus).
• Diverse clinical experience.
• Experience or Certification in Case Management preferred.
• Understanding of Case Management functions, self-funded insurance plans and PPO networks.
• Knowledge of medical/health insurance terminology, ICD-9/ICD-10, HIPAA and DOL regulations.
• Strong interpersonal skills and the ability to work effectively with a diverse patient population.
• Participation on a Pulse Committee is strongly encouraged within 1 year of hire.
• Interest in future leadership development opportunities preferred.
• Ability to communicate effectively, both verbally and in writing, medical information to health care professionals, employer groups, brokers, stop loss, internal customers, members and families.
• Ability to work independently under general instruction and with a team.
• Time management, organizational, research, analytical, and documentation skills.
• Experience using a video-conferencing system.
• Types 45 wpm, 10-key and computer knowledge.
• Able to demonstrate excellent attendance and punctuality.
• Excellent customer service attitude and professionalism.
• Demonstrate Accuracy, Customer Service, Timely Turn-Around (ACT).
• Exceptional verbal and written communication skills.
• Proficiency using Microsoft Office (Word, Excel, Outlook, etc.).
• Ability to work efficiently, perform multi-tasking, prioritize tasks, and meet tight deadlines.
• Possess a high degree of integrity and discretion, as well as the ability to adhere to both company policies and best practices.
• Ensure compliance with security practices and procedures, including HIPAA and HITRUST standards.
• Ability to efficiently and effectively perform the Key Result Areas with or without a reasonable accommodation without posing a direct safety threat to others or self.
• Protect and enhance the Core Purpose and the Core Values of AmeriBen.

AmeriBen is an Equal Opportunity/Affirmative Action Employer committed to creating an environment of diversity and inclusion for equal employment and advancement opportunities to all employees and applicants for employment. All qualified applicants will receive consideration for employment without regard to race, religion, color, age, national origin, sex, sexual orientation, gender identity and/or expression, genetic information, disability, veteran or military status, or any other category protected by federal, state and/or local law.

If you are unable to use our online application process due to a disability, please contact the Human Resources Department at humanresources@ameriben.com.