Utilization Management Nurse, Out of Network
Core
Review prior authorization requests for planned inpatient or outpatient services from out-of-network providers to assess medical necessity and benefit coverage.
Role type
Utilization Management Nurse (UMN)
Builds
Authorization decisions and network adequacy reviews for ACO, HMO, and EPO members
Domain
Healthcare / Managed Care
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical review expertise, Medical necessity assessment, Benefit coverage determination, InterQual utilization review, Prior authorization experience, Commercial health plan knowledge
Preferred skills
Payer setting experience, Acute care setting experience, Milliman experience
Technologies
InterQual, McKesson InterQual, Microsoft Word, Excel, Outlook, SharePoint
Responsibilities
Review authorization requests for medical services and make initial eligibility and coverage determinations, Manage incoming requests for procedures and services including patient medical records, Render approval decisions within scope and determine when physician review is required, Complete determinations following physician review, Adhere to program and organizational performance metrics
Seniority
Mid-level, hands-on IC