RN Utilization Management Review - MercyCare

Responsible for coordinating utilization review (UR), case management and NCQA/quality initiative activities for all managed products. Attends and contributes as required to physician committees such as medical management as assigned.

Essential Duties and Responsibilities

• Demonstrates commitment to quality by providing excellent service to internal and external customers.

• Ensures all work activities are consistent with managed care policies and philosophy follows directives from the legal department and is responsible for all extra contractual arrangements.

• Completes work accurately and in a timely manner.

• Knowledge of health care delivery systems, medical necessity criteria application and legal consideration, surrounding managed care' proven excellence in communication; these skills include writing, speaking and presenting to professionals, demonstrates ability to work within a team environment.

• Demonstrated knowledge of NCQA UM requirements.

• Meets NCQA standards of documentation

• Assists with developing and updating policies and procedures for the Quality Health Management department

• Skillfully interacts professional in a persuasive manner with physicians and other health care professionals

Education and Experience

Graduate of an accredited nursing program.

BSN or upon hire BSN completion agreement for enrollment in an accredited BSN Completion Program

May require specific years of applicable experience to qualify (per department guidelines). If hired prior to 1-1-14 in Winnebago County and prior to 9-1-14 in Rock, Walworth and McHenry Counties an ADN only is required.

Certification and Licensure

Licensed as an RN in state of practice-Wisconsin and Illinois

Mathematical Skills

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Computer Skills

To perform this job successfully, an individual should have a high-level knowledge or capacity to learn various database programs, software and Word Processing software.

May include color blind test (per department guidelines)

Mercyhealth offers a generous total rewards package to eligible employees including, but not limited to:

* Comprehensive Benefits Package: Mercyhealth offers a retirement plan with competitive matching contribution, comprehensive medical, dental, and vision insurance options, life and disability coverage, access to flexible spending plans, and a variety of other discounted voluntary benefit options.

* Competitive Compensation: Mercyhealth offers market competitive rates of pay and participates in various shift differential and special pay incentive programs.

* Paid Time Off: Mercyhealth offers a generous paid time off plan, which increases with milestone anniversaries, to allow employees the opportunity for a great work-life balance.

* Career Advancement: Mercyhealth offers a number of educational assistance programs and career ladders to support employees in their educational journey and advancement within Mercyhealth.

* Employee Wellbeing: Mercyhealth has a focus on wellbeing for employees across the organization and offers a number of tools and resources, such as an employer-sponsored health risk assessment and a Wellbeing mobile application, to assist employees on their wellbeing journey.

* Additional Benefits: Mercyhealth employees have access to our internal and external employee assistance programs, employee-only discount packages, paid parental and caregiver leaves, on-demand pay, special payment programs for patient services, and financial education to help with retirement planning.