FargoRecruiter Since 2001
the smart solution for Fargo jobs

Utilization Management Reviewer RN

Company: Blue Cross Blue Shield of ND
Location: Fargo
Posted on: December 4, 2019

Job Description:

Employer Blue Cross Blue Shield of ND Location Fargo, North Dakota Salary Join our team! Posted Nov 19, 2019 Ref UTILI01554 Industry Healthcare Role Manager Job Type Long-Term Hours Full Time You need to sign in or create an account to save Job Summary The Utilization Management Reviewer (RN) processes pre-service requests in a timely and accurate manner reviewing requests for completeness and for appropriate insurance coverage. This position selects from and uses multiple data sources to make a medical necessity determination and may refer to medical review or case management. The Utilization Management Reviewer (RN) responds to the provider with a decision and rationale discussing the case, providing additional information and explanation for the decision, if necessary. Essential Functions Considers and identifies multiple factors to determine the level of medical review necessity, this includes, but is not limited to: reviews member and benefit eligibility, conducts medical necessity for preauthorization, prior approval and courtesy predetermination requests and applies medical policy and evidence based medicine guidelines and research in the absence of an established policy or guideline. Requests additional documentation and clarifies information to substantiate utilization management decisions as per the standard nursing process for assessment and evaluation. Completes all necessary documentation to relay decision. Communicates decision in written form for rejections, follows up directly with provider to explain and discuss. Identifies trends and aberrancies related to medical necessity and utilization patters. Serves as a medical resource for the organization and provide guidance and direction on matters such as workflow processes and criteria development as related to medical policy and utilization management. Collaborates with internal staff and external providers to provide outcome, refer to complimentary programs and provides additional instruction. Monitors for under and over-utilization practice patterns. Prioritizes workloads to ensure timeliness standards and inventory levels are maintained. Knowledge, Skills and Abilities Attention to Detail and Accuracy Advanced Communication (Verbal/Written) Intermediate Nursing Expertise Advanced Task and Goal Focus Intermediate Analytical Thinking Intermediate Education Requirements Required: Associate's Preferred: Bachelor's Field(s) of Study: Completion of RN program is required; BSN is highly preferred Experience Requirements Required: Minimum of 3 Years Preferred: Minimum of 5 Years Experience Details: Minimum of 3 years of clinical/patient care or related experience is required; variety of clinical, hospital, skilled nursing experience is highly desirable; candidate must possess in-depth medical knowledge, critical thinking skills and expertise in interpretation and application of medical policy/criteria, utilization management processes, medical criteria/guidelines, contract benefits and the ability to research medical diagnoses, procedures and technology. Certification, Licensures & Registration Requirements Title: North Dakota (ND) Registered Nurse (RN) License or RN License valid for work in ND State or Agency: Board of Nursing Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards Other Information Job Posting Policy 6.05 New employees with Blue Cross Blue Shield of North Dakota will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply. Equal Opportunity Employment Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity. For questions, please email ****************** This job posting will be closed 12/3/2019 at 8:00AM CST. No further applications will be considered.

Keywords: Blue Cross Blue Shield of ND, Fargo , Utilization Management Reviewer RN, Executive , Fargo, North Dakota

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category

Other Executive Jobs

Air Defense Battle Management System Operator
Description: Company: Army National Guard Contact: Post Date: 12/06/19 Phone: Job Type: Part Time Fax: Reference: NDg8AI4dEm Mailing Address: AGE REQUIREMENTS: Must be between the ages of 17 and 35Defend the skies (more...)
Company: Army National Guard
Location: Grand Forks
Posted on: 12/11/2019

Director Global Financial Reporting - CPA required
Description: Love your job We have an immediate need for a Director Global Consolidations and External Financial Reporting Private Equity for a B , growing organic acquisitions , multi-vertical manufacturing (more...)
Company: Job Juncture
Location: Fargo
Posted on: 12/14/2019

VP Controller
Description: You will provide leadership for assigned staff maintain accounting expertise and supervisory skills, implementing new regulatory, GAAP and FASB direction lead in development
Company: AgCountry Farm Credit Services
Location: Fargo
Posted on: 12/15/2019

Franchised Sales Manager
Description: position. It is a job opportunity with one of Marriott International s franchisees. Please apply via email at: Additional Information:This hotel is owned and operated by an independent (more...)
Company: Delta Hotels and Resorts
Location: Fargo
Posted on: 12/12/2019

RN Case Manager Inpatient - Case Management
Description: Employer Sanford Health Location Fargo, North Dakota Salary Join our team Posted Dec 07, 2019 Ref 16655 Industry Healthcare Role Nurse Job Type Long-Term You need to sign in or create an account to save (more...)
Company: Sanford Health
Location: Fargo
Posted on: 12/14/2019

COBRA Client Manager
Description: The COBRA Client Manager is responsible for implementing/managing a partner s COBRA program as it pertains to all aspects of the service model. They will also serve as a main point of contact for the (more...)
Company: WEX, inc.
Location: Fargo
Posted on: 12/14/2019

Software Development Manager
Description: SOFTWARE DEVELOPMENT MANAGERThe WEX Software Development Manager leads a team of talented Software Engineers and is directly responsible for contributing to the WEX Health Cloud Platform. The role actively (more...)
Company: WEX, inc.
Location: Fargo
Posted on: 12/12/2019

Senior Project Manager, Small & Medium Business
Description: Our Culture: br br Stoneridge Softwarebeganwith an idea: Howcan Microsoft implementations be done better After considering the idea for some time, Eric Newell created Stoneridge Software, whichhas (more...)
Company: Stoneridge Software
Location: Fargo
Posted on: 12/14/2019

Manager, Comm Data Business
Description: Manager, Comm Data Business North Dakota-Fargo Graybar is looking for talented, enthusiastic people to help us maintain the highest levels of customer satisfaction in every area of our business. We are (more...)
Location: Fargo
Posted on: 12/15/2019

Building Facilities Manager
Description: The Forum of Fargo-Moorhead is a family-owned newspaper and communications company that has been in operation for more than 125 years. We are located in the heart of downtown Fargo and not too far from (more...)
Company: The Forum of Fargo-Moorhead
Location: Fargo
Posted on: 12/10/2019

Log In or Create An Account

Get the latest North Dakota jobs by following @recnetND on Twitter!

Fargo RSS job feeds