Utilization Management Nurse

QUALIFICATIONS

• Ohio Licensed Registered Nurse
• May also have certification as a case manager {Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Nurse (CRRN), Certified Occupational Health Nurse (COHN).
• A minimum of three (3) years of full-time direct care in a health and human services profession; preferably in occupational health or rehabilitation
• Maintains continuing education as required to maintain licensure and certification
• Excellent leadership, verbal/written communication skills, strong organizational skills, and excellent decision making

ROLE AND RESPONSIBILITIES

• Reports to the UM Team Lead
• Act as a liaison between the case manager and the provider/injured worker and all other parties to the claims related to C9-Treatment Authorization Request(s)
• Utilizes Director of Medical Management and/or UM Team Lead as a resource for all clinical questions and advice
• Serve as the first point of contact for treatment plans (C-9).
• Follow up with all necessary parties regarding treatment requests including injured workers, providers, employers, legal representatives, TPA's, MCO Case Managers and BWC staff.
• Assess the appropriateness and medical necessity of the treatment requests for utilization review on a prospective, concurrent, and retrospective basis.
• Coordinate and review the C-9 request and follows the C9 Policy and Procedures to maintain compliance with BWC Policy Reference Guide
• Assess quality and clinical risk issues on a concurrent basis; report any recognized issue to the Team Leader/Supervisor
• Assess documentation of medical records for completeness and relationship to the treatment plan
• Ability to obtain and interpret information appropriate to injured workers needs as required for assessment, treatment, and patient care services
• Initiate communication as necessary with the injured worker, employer, provider, BWC, and TPA regarding the treatment plans as well as coordinate services with other UniComp departments
• Provide education and guidance to all parties to the claim
• Evaluates the Treatment request(s) for cost utilization, appropriateness for treatment of conditions allowed in the claim and facilitation of the best possible outcome(s) for the injured worker
• Adheres to Chapter 3, of the MCO/BWC Policy Reference Guidelines related to C9 requirements
• Develop and maintain a positive work atmosphere and support the overall team; demonstrate ability to work in a team environment
• Maintain Confidentiality
• Work independently, efficiently and prioritize effectively
• Practice nursing within the Scope of Practice as designated the State Of Ohio Board Of Nursing
• Respond promptly to email and phone call communication
• Utilize and interpret Official Disability Guidelines and/other treatment guidelines

This job description is not intended to be all inclusive and the employee will also perform other reasonably related business duties as assigned by the immediate supervisor and other management as required.

Current Openings for Utilization Management Nurse Jobs at DO NOT USE Sheakley Group, Inc DO NOT USE