Employer Industry: Healthcare Services

Why consider this job opportunity:
- Salary up to $84,456 annually
- Excellent fringe benefit package including medical, dental, vision, life, and long-term disability insurance
- Generous retirement savings plan
- Flexible work schedules with hybrid/remote options
- Paid time off including vacation, sick leave, holidays, and management leave
- Opportunity to work collaboratively across departments to improve patient care

What to Expect (Job Responsibilities):
- Independently conduct medical necessity reviews of service requests against established clinical guidelines
- Ensure authorized services meet service needs and compliance with medical policy, member eligibility, and contracts
- Conduct utilization reviews to monitor adherence to clinical practice guidelines
- Maintain open communication with staff, providers, and community agencies regarding consumer care
- Participate in the integration of Utilization Management processes into the organization’s mission

What is Required (Qualifications):
- Graduation from a state-accredited school of nursing or an Associate’s Degree in Nursing with five years of nursing experience, or a Bachelor’s degree in Nursing with three years of nursing experience
- Current, active, and unrestricted North Carolina clinical license as a Registered Nurse, or a compact license
- Knowledge of physical health and co-morbid health conditions
- Proficient in the use of computer and multiple software programs
- Strong written and oral communication skills

How to Stand Out (Preferred Qualifications):
- Experience in Utilization Management
- Knowledge of Utilization Management managed care principles and strategies
- Ability to assist appeal efforts when medical care is denied by payor entities
- Experience with NCQA standards
- Ability to analyze and adjust processes for effectiveness

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