What are the responsibilities and job description for the RN Utilization Management Review - MercyCare position at Mercyhealth?
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)