UM BH Registered Nurse
About the role
The DOW SkillBridge Internship and Military Spouse Fellowship Programs provide training and support to transitioning military service members and military spouses. The Utilization Management Behavioral Health Registered Nurse (RN) Intern will work with a National Medicaid team to conduct medical necessity reviews for behavioral health services.
Responsibilities
Conduct comprehensive clinical reviews of prior authorization requests to determine medical necessity and benefit eligibility.
Apply advanced evidence-based clinical guidelines in review decisions.
Ensure compliance with accreditation, state, and federal regulations.
Communicate with healthcare providers to obtain necessary clinical information and clarify requests.
Cookordination with medical directors and interdisciplinary teams to support decision-making.
Promote communication between clinicians, internal departments, and members.
Document all review findings and decisions in clinical documentation systems.
Support reporting programs and provide data for performance improvement projects.
Implement quality assurance measures to ensure accuracy and consistency in prior authorization decisions.
Conduct regular audits and reviews to maintain high standards of service.
Identify process improvement opportunities and contribute to performance improvement projects.
Educate providers and staff on prior authorization policies, criteria, and review processes.
Provide mentorship and feedback to nonclinical staff and peers to enhance workflow efficiency.
Stay current with clinical best practices and regulatory changes.
Requirements
Be a transitioning service member eligible to participate in the DOW SkillBridge or a military spouse eligible to participate in the military spouse fellowship.
Have an Active Registered Nurse, RN, license in the state of Kentucky or an enhanced Compact (eNLC) license without restrictions or disciplinary action.
Have at least two (2) years of clinical behavioral health experience.
Proficiency in healthcare software and electronic medical records (EMR) systems.
Preferred Qualifications
Bachelor's degree.
Previous Medicare/Medicaid experience.
Previous experience in prior authorization, utilization management.
Experience working with MCG or Interqual guidelines.
Certification in Case Management (CCM) or Utilization Review (UR).
Knowledge of payer policies, insurance companies and government health programs.
Workstyle
Remote Work at Home Location: Must reside in a state that participates in the enhanced compact license (eNLC). Work Schedule: Weekdays 8:00 AM to 4:30 PM Central Time. Travel: None.
Additional Information
The DOW SkillBridge Internship Program provides transitioning military service members time to gain civilian work experience while still on active duty with an employer for a period approved by their command and the DOW, with an average timeline of 90 days. The Military Spouse Fellowship Program connects military spouses with employers offering a variety of professional onsite, field, or remote based opportunities for a period up to 12 weeks. Networking opportunities will be provided while participating in the Internship or Fellowship. Due to factors such as location, and/or requirements that cannot be modified, full-time employment is not guaranteed upon completion of the Internship or Fellowship.