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Remote Utilization Management Clinician (LPN, BSN)

Company: Elohim Group LLC
Location: Lees Summit
Posted on: January 9, 2021

Job Description:

SCOPE OF ROLEThe Utilization Management Clinician uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. This role makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed while following established guidelines/procedures.ROLE RESPONSIBILITIESRESPONSIBILITIES % OF TIME1. Provides first level clinical review for all medical and surgical authorization requests against applicable criteria, policies and procedures. Accurately documents all reviews and contacts providers and members according to established timeframes. 80%2. Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost-effective care delivery. 10%3. Screening and coordination of cases within the utilization management department and other Bright clinical teams including Case Management, Care Navigation and Transitions of Care to ensure optimal care for members 5%4. Escalates all potential quality issues and grievances to correct Bright workflows 5%Experience/Requirements:

  • Graduate of Nursing program required; BSN desired
  • Active clinical licensure in good standing with state of MO
  • Three (3)+ years of utilization management/quality improvement experiencepreferred. (will consider candidates with 1+ years experience)
    • Working knowledge and understanding of basic utilization management concepts.Nice to have's:1. Experience with MA(Medicare Advantage) and IFP (Individual Family Plans)
      • REMOTE role, but must live within one hour of Lee's Summit (Kansas City, MO suburb)so candidate can drive in for the occasional team meeting. 6 - 8 weeks of initial onsite training before full remote work.LICENSURES AND CERTIFICATIONSActive clinical licensure in good standing with current state, MOJob Type: Full-time, RemoteLocation: Lee's Summit, MO (Kansas City, MO suburb)Benefits: Medical, Dental, Vision. HSA, FSA. EAP, Commuter Benefits, 401K, PTO, Parental Leave

Keywords: Elohim Group LLC, Lee's Summit , Remote Utilization Management Clinician (LPN, BSN), Executive , Lees Summit, Missouri

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