UR/CM Behavioral Health Registered Nurse

    • Job Tracking ID: 512935-764023
    • Job Location: Remote, USA
    • Job Level: Mid Career (2+ years)
    • Level of Education: 2 year degree
    • Job Type: Full-Time/Regular
    • Date Updated: April 13, 2021
    • Years of Experience: 2 - 5 Years
    • Starting Date: ASAP
    • Salary Type:: Salary
    • Rate:: 60,000 + DOE
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Job Description:

Job Purpose

The Utilization Review/Case Management Behavioral Health Registered Nurse utilizes advanced clinical judgment, critical thinking skills and medical guidelines in a collaborative process to assess, coordinate, monitor and evaluate options to facilitate appropriate physical and behavioral healthcare services/benefits for members. Coordinates medical and Mental Health/Substance Use Disorder service requests from providers and determines medical necessity using internal guidelines, clinical experience/judgment and the specific requirements of the member’s health plan. Promotes effective utilization of available resources, optimal member functioning, and cost-effective outcomes through assessment and member-centered care planning, provider coordination/collaboration, and coordination of psychosocial services.




Key Functions


  • Conducts telephonic utilization review/precertification services including, prospective, concurrent and retrospective review utilizing clinical/behavioral health criteria guidelines, clinical 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/behavioral health criteria guidelines.
  • Assesses the member's current status, future care needs and treatment plan.
  • Telephonic communications with members to address their bio-psychosocial needs, identify opportunities for improved health care, and facilitate resources. Use of motivational interviewing to facilitate member empowerment.
  • 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, Health 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 on-site weekly company/team meetings and monthly staff meetings.
  • Performs all duties within the scope of her/his licensure.
  • Performs other duties as assigned or needed.


Experience and Skills:

Minimum Qualifications and Education

  • * Current active and unrestricted licensure as Registered Nurse.
    • 3-5 years of clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
    • Case management and discharge planning experience required.
    • Crisis intervention skills preferred.
  • Associates Degree in Nursing (Bachelor’s Degree is a plus).
  • Two (2) years of clinical or utilization review experience preferred.
  • Strong interpersonal skills, motivational interviewing skills, and the ability to work effectively with a diverse patient population.
  • 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.
  • 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).
  • 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.




Preferred Qualifications

  • Certification in Case Management (CCM) desired.
  • Knowledge of UR/Case Management functions, self-funded insurance plans, networks and coding preferred.

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