Utilization Management Nurse (RN)
Location: Helena Montana
Description: Blue Cross and Blue Shield of Montana is presently looking of Utilization Management Nurse (RN) right now, this occupation will be placed in Montana. For complete informations about this occupation opportunity please give attention to these descriptions. Blue Cross and Blue Shield of Montana (BCBSMT) is seeking a Registered Nurse with a current, unrestricted Montana Nursing License to join our team as a Utilization Management Nurse (RN) in our Helena, MT office. You will apply your clinical knowledge to optimize benefits based on BCBSMT member care needs, validate hospital admissions according to nationally recognized standards (Milliman Care Guidelines), and assess inpatient events for compliance with the Utilization Review Plan filed with the State of Montana and URAC standards. To qualify you must have three years of recent med-surg health care experience (within the past five years) and one year of experience in utilization management, quality improvement, or discharge planning; and three years of recent health care experience in acute care nursing in the areas of medical, surgical, or emergency services, or certification review experience or an equivalent combination of education and experience.If you possess demonstrated knowledge of nursing and health care principles and modern practices and principles of medical disease counseling, and understand managed care, health care benefits, and third-party reimbursement, this may be a good opportunity for you!Essential Duties & Responsibilities: Certify all impatient admissions and conducts concurrent reviews for ongoing inpatient stays using published nationally recognized criteria as chosen by BCBSMT and in keeping with the contract benefit. Refer identified patients who are medically complex and require intensive medical or psychosocial support to Case Management following establish criteria/trigger list. Document all Utilization Management activity and correspond within the established timeframes. Apply clinical knowledge to optimize benefits based on member care needs. Seek to identify and implement the most appropriate high quality, cost effective health care services alternatives that best meet the individual patients needs. Assist in establishing and maintaining review criteria, protocols, and procedures. Assess the service request for effectiveness and appropriateness to determine that care to be delivered meet the members needs. Establish and maintain collaborative relationships with internal claims team members, medical providers, members and other external managed care vendors (Paradigm, DME, Pharmacy, etc.). Facilitate event closure based on established goals and objectives. Conduct quality assurance/improvement (QA/QI) reviews on a regular basis. Maintains accurate member records and confidentiality. Promote customer satisfaction designed to achieve established goals and objectives. Minimum Requirements: Registered Nurse with a current, unrestricted Montana Nursing License. Two years of recent health care experience (within the past five years) and one year of experience in utilization management, quality improvement, or discharge planning. Three years of recent health care experience in acute care nursing in the areas of medical, surgical or emergency services, and/or certification review experience or an equivalent combination of education and experience. Demonstrated knowledge of nursing and health care principles, procedures, methods and techniques. Knowledge of modern practices and principles of medical disease counseling. Working knowledge of resources internal and external to a health plan including network and benefit structures. Solid understanding of managed care, health care benefits, and third party reimbursement. Knowledge of federal and state statutory and URAC requirements. Working knowledge with Microsoft Office suite and internet search tools. Additional Skills of Interest: Knowledge and experience with various BCBSMT systems and data such as membership, claims, and benefit plans is preferred. Knowledge and experience in utilization management is preferred. Ability to establish priorities and work independently. Excellent interpersonal skills, phone manners, and organizational skills. Additional industry certifications are desirable, but not required. Benefits That Make a Difference!Blue Cross Blue Shield of Montana offers its employees benefits that are truly comprehensive, competitive and affordable. We offer the following health, educational and lifestyle benefits: Excellent starting salary Exceptional benefits package including medical, dental, vision, and prescription coverage 401k with company match Retirement plan Vacation and personal time Tuition reimbursement Wellness program Paid time off for community service activities If you would like to be a part of Blue Cross and Blue Shield of Montana and our commitment to Montana, please apply online today at www.bcbsmt.com. In addition to submitting your information online, at the same time please complete the employment application on our website and email to applications@bcbsmt.com with the position title as the subject line. A complete application must be submitted to be considered.This position will remain open until filled, but materials received by 5pm September 11, 2012 will be considered during the first review. Further application reviews will be done only if needed. An Equal Opportunity Employer
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If you were eligible to this occupation, please email us your resume, with salary requirements and a resume to Blue Cross and Blue Shield of Montana.
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This occupation starts available on: Wed, 29 Aug 2012 13:33:49 GMT