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Registered Nurse I (AL)
Ref No.: 20-01593
Location: Birmingham, Alabama
Address: 2 Chase Corporate Dr, STE 300
Hours: Monday through Friday; 8am to 4:30pm
Pay: $35.98 an hour, paid every Friday! 
Start: 04/01/2020

  • Responsible for collaborating with healthcare providers and members to optimize member benefits and to promote effective use of resources.
  • Assesses the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, and out of network services.
  • May also manage appeals for services denied. May conduct pre-certification, concurrent and retrospective reviews to ensure compliance with medical policy, member eligibility, benefits, and contracts.
  • May be responsible for day-to-day operations of a single or multiple IPA/IPOD and staff, and may serve as liaison with the local health plan to ensure continuity for IPA/IPOD members.
Essential Duties and Responsibilities:
  • Responsible for the effective and sufficient support of all Utilization Management activities to include prospective/pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies.
  • Uses an established set of criteria, evaluates and authorizes the medical necessity of some inpatient and outpatient services.
  • Notifies provider of recommended changes in level of care.
  • Evaluates cases for quality of care and documents quality issues.
  • Issues letter to provider and member if the service meets certification criteria, and escalates to manager or Medical Director for review if the service does not meet certification criteria, and may issue denial letters.
  • May participate or assist in the planning of team, UM/QM, PCP, IPA and or Health Plan meetings.
  • Works with management team to achieve financial goals and operational objectives
  • Knowledge, Skills, Abilities Required:
  • Excellent interpersonal and communications skills with clinical staff, management, and all departments involved in the care of our customers.
  • Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments
  • Ability to make decisions on what needs to be done based on clearly established guidelines
  • Able to work in a dynamic, fast-paced team environment and to promote team concepts
Computer Skills:
  • Substantial knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel and Word.
  • At least one year clinical experience.
  • Excellent communication and interpersonal skills.
  • Excellent time management skills.
  • Working knowledge of the insurance industry and the overall claims process a plus.
  • Knowledge of UM and CM products.
  • Proficient in basic computer skills
  • At minimum - Associate's Degree Required
  • Current licensure as a Registered Nurse in state they will be working in required
  • English Read Write Speak