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Utilization Management Specialist

Utilization Management Specialist

SnaphuntOman
27 منذ أيام
الوصف الوظيفي

The Offer

  • Fantastic work culture

The Job

Key Responsibilities

  • Conduct prior authorization, concurrent, and retrospective reviews for various healthcare services, including inpatient, outpatient, home health, and behavioral health.
  • Apply evidence-based criteria (e.g., MCG, InterQual) to assess the necessity of medical services.
  • Collaborate with healthcare providers, medical directors, and clinical staff to facilitate appropriate care plans and resource utilization.
  • Maintain accurate and organized documentation of all utilization management activities.
  • Participate in quality improvement initiatives and assist in developing clinical guidelines.
  • Monitor and report on utilization trends to management, identifying areas for improvement.

    • The Profile

    Qualifications

  • Bachelor's Degree in Nursing (BSc Nursing) or equivalent.
  • Minimum of 2 years of clinical experience in a hospital or healthcare setting.
  • Active and unrestricted Registered Nurse (RN) license in the United States.
  • Familiarity with utilization management processes and guidelines (e.g., MCG, InterQual).
  • Proficient in medical terminology, anatomy, and physiology.
  • Strong analytical and problem-solving skills.
  • Excellent communication skills, both written and verbal.
  • Proficient in Microsoft Office applications.

    • Preferred Qualifications

  • Experience with Medicaid, Medicare, and Managed Care programs.
  • Previous experience in utilization review or case management.
  • Certification in Case Management (CCM) or Accredited Case Manager (ACM) is a plus.

    • The Employer

    Our client specializes in Healthplan IT solutions, offering a comprehensive suite of services designed to enhance efficiency and improve digital presence for health plans and Third-Party Administrators (TPAs).

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    Utilization Management Specialist • Oman

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