UM Nurse Specialist

Experience & Requirements

• Experience Level: 3 - 5 year’s experience in utilization management, case management, quality management. Experience with InterQual and/or Milliman Care guidelines preferred. Strong organizational and time management skills.
• Tools and Technology: Computer usage for word processing, spreadsheets, email, internet, medical records and other proprietary company/client systems.
• Certificates and Licenses: Registered Nurse (RN) active license
• Language Ability: Strong verbal, written communication skills. Effectively present information in one-on-one and group situations to nursing staff, clients and other employees of the organization.
• Reasoning Ability: Ability to work on extremely complex problems where analysis of situations or data requires an evaluation of intangible variance factors.
• Work Environment: Office environment with occasional travel up to 10% to regional offices, client and/or vendor sites.

A background check, security clearance and drug screening are required for this role.

YesCare is an Equal Opportunity/Affirmative Action Employer. In compliance with federal and state employment opportunity laws, qualified applicants are considered for all positions without regard to race, gender, national origin, religion, age, sexual orientation, disability, Vietnam era veteran, or disabled Veteran status. EOE including Disability/Protected Veterans _._

Responsibilities

Below is a list of your responsibilities as a Utilization Management Specialist 2 with YesCare :

• Responsible for the implementation of a comprehensive outpatient/inpatient review process utilizing criteria based review standards and standards of best practice.
• Facilitate quality health care intervention recommendations.
• Review and assess over/under utilization issues.
• Track, trend and evaluate appropriateness and quality of care issues with the implementation of education to internal and external customers and process improvement initiatives.
• Respond to inquiries by provider/site employees relating to standards of care and best practices.
• Develop and maintain pre-established review parameters under the direction of theYesCareMedical Director.
• Identify and document comparisons with community standards, regionally based as indicated.
• Communicate and guide staff and physicians regarding utilization management program development, implementation, evaluation and reporting.
• Work with other UM inpatient and outpatient nurse reviewers to assure proper treatment in the appropriate setting at the appropriate time.
• Communicate and document any issues relating to the outpatient/inpatient UM process to the Manager of Utilization Management.
• Assist with the data collection and reporting related to the UM outpatient/inpatient process.
• Participate in CEU offerings/seminars to enhance professional growth and development and the maintenance of nursing license.
• Recommend improvements to process and outcomes using data analysis tools, logical rules/relations and data elements.
• Performs miscellaneous job-related duties as assigned.

YesCare Benefits (only applicable for full-time positions)

• Health, Dental and Vision Insurance
• Life and Disability Insurance
• Generous PTO plan
• 401k with matching funds
• Employee Discount and Rewards Program
• Tuition Assistance
• Continuing Education Reimbursement

About YesCare Health

Correctional healthcare is not just a job. It’s a calling.

By choosing a career with YesCare, you are choosing the opportunity to truly make a difference in the health, well-being, and future of the patients you serve. We take pride in being a pioneer provider of correctional healthcare. As a YesCare professional, you have access to the resources and support to enhance your skills, build a solid foundation to reach your career potential, and contribute to the care and well-being of an underserved population. There is no greater calling. Join YesCare today and be part of our legacy of innovation and clinical expertise.

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ID 2024-18269

Job Locations US-TN-Brentwood

Category Corporate

Position Type Regular Full-time

Shift / Schedule Weekday Day

Location ID 99610