Utilization Management Clinical Reviewer

About the role

The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources. This role requires active, unrestricted RN licensure, US citizenship, and a favorable Department of Defense background investigation.

Responsibilities

• Reviews and makes determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan.
• Applies clinical knowledge to complete review using clinical criteria and policy keys.
• Documents in the medical management information system.
• Prepares and presents more complex cases for Medical Director Review.
• Refers cases to Case Management and Disease Management as appropriate.
• Advises non-clinical staff on clinical and coding questions.
• Conducts pre-admission screening and assessments.

Requirements

• 2+ years clinical experience
• 2+ years Utilization Management experience
• Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and outlook)
• Demonstrates effective verbal and written communication skills

Preferred

• 3+ years Medical / Surgical experience
• Behavioral Health experience
• 1 year TriWest or TRICARE experience
• Managed Care experience

Skills

Key skills include communication, computer literacy, coping/flexibility, empathy/customer service, independent thinking/self-initiative, high intensity environment, organizational skills, team-building/team player, and technical skills.

Benefits

Includes medical, dental and vision coverage, paid time off, 401(k) retirement savings plan (with matching), short-term and long-term disability, basic life, and accidental death and dismemberment insurance, tuition reimbursement, and paid volunteer time. Salary range is approximately $88,000 - $93,000 per year.

Pay

Salary range is approximately $88,000 - $93,000 per year.

Schedule

Ability to cover any work shift and work overtime, if needed.

Company Overview

Taking Care of Our Nation’s Heroes. It’s Who We Are. It’s What We Do. Do you have a passion for serving those who served? Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve®!

Equal Employment Opportunity

We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply.