UR/CM Behavioral Health Registered Nurse

    • Job Tracking ID: 512935-779634
    • Job Location: Remote, USA
    • Job Level: Mid Career (2+ years)
    • Level of Education: 2 year degree
    • Job Type: Full-Time/Regular
    • Date Updated: July 01, 2021
    • Years of Experience: 2 - 5 Years
    • Starting Date: August 2, 2021
    • Salary Type:: Salary
    • Rate:: 60,000 + DOE
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Job Description:

Salary $60-65K DOE

Job Purpose

The Utilization Review/Case Management Behavioral Health Registered Nurse utilizes advanced clinical judgment, critical thinking skills and criterial 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 criteria guidelines/medical policies 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 information provided, criteria guidelines, medical policies, and the specific requirements of the member’s health plan. Forwards reviews to the Medical Director 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, medical policies and plan language.
  • Assesses the member's 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.
  • Conducts post hospitalization calls.
  • 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.
  • Attends weekly company/team meetings and monthly staff meetings.
  • Ensures compliance with security practices and procedures, including HIPAA and HITRUST standards.
  • Protects and enhances the daily culture and environment of AmeriBen.  Fosters, supports, and demonstrates the company Core Purpose and Core Values.
  • Performs all duties within the scope of her/his licensure.
  • Performs other duties as assigned or needed.


Experience and Skills:

  • Current unrestricted RN license
  • Associates Degree in Nursing (Bachelor Degree is a plus).
  • 3-5 years of clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.
  • Proficiency with Microsoft Office products (Word, Excel, Outlook, etc.).
  • Strong verbal and written communication skills.
  • Knowledge of medical/health insurance terminology, ICD-10/ICD-11, HIPAA and DOL regulations.
  • Experience using video conferencing.
  • Excellent customer service attitude, accuracy, and professionalism.
  • 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.

Preferred Qualifications

  • Experience in Utilization or Case Management or Certification in Case Management preferred.
  • Discharge planning and crisis intervention skills preferred.
  • Understanding of UR/Case Management functions, self-funded insurance plans and PPO networks.
  • Types 45 wpm, 10-key, and computer knowledge.
  • Strong interpersonal skills, motivational interviewing skills, and the ability to work effectively with a diverse patient population
  • Interest in future leadership development opportunities preferred.
  • Effective communication, both verbally and in writing.

AmeriBen is not yet hiring in the below states.

Alabama Delaware Massachusetts Montana New Hampshire New Mexico  New York  North Dakota Rhode Island South Dakota Vermont

AmeriBen is an Equal Opportunity 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.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. If you are unable to use our online application process due to a disability, please contact the Human Resources Department at humanresources@ameriben.com or call 208-488-7654.