Temporary UM Nurse

Minimum Qualifications:

  • Bachelor’s Degree in Nursing; five (5) years of clinical care or nursing experience; OR an equivalent combination of education and experience and two (2) years experience in Utilization Review and/or Quality
  • Licensed as a Registered Nurse by the State of MA and remain active with all annual licensing requirements
  • Proficiency with MS Office products to include Outlook, Excel, PowerPoint, and Word
  • Strong communication, documentation, clinical and critical thinking skills

Preferred Qualifications:

  • Health insurance industry experience
  • Working knowledge of utilization management/case management

Essential Job Duties and Responsibilities:

  • Refer appropriate cases to contracted vendors for case management and clinical reviews
  • Prepare case reviews for complex or high $$$ claims
  • Review claims and precertification requests when asked to do so by supervisor
  • Review prior authorization requests on medical services
  • Make sound judgement on prior authorization using clinical guidelines and refers for medical peer review to support denial decisions
  • Communicates directly with health care providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services
  • Participates in UM program, case reviews and quality program
  • Follows relevant client and state mandated time frame standards for conducting and communicating UM review determinations
  • Maintain logs on review activities and present reports for supervisor  
  • Submits case management referrals on catastrophic, complex and high-risk cases and communicates to internal stakeholders
  • Participates in ad hoc projects per supervisor
  • Works with other departments to support clinical department needs
  • Supports claims department, claim examiners and CSR’s

Perform other duties as assigned, or situation dictates

 

Please send your resume and completed application to CHP Human Resources at:

Mail: Consolidated Health Plans, Human Resources, 2077 Roosevelt Avenue, Springfield, MA 01104-3503

Fax: (413) 452-5329 Attn. Human Resources

Email: human_resources@consolidatedhealthplan.com

Phone: (413) 733-4540 ext. 120

 

Employment Application

Download Employment Application

 

For more information contact us at human_resources@consolidatedhealthplan.com or call us at (413) 733-4540 ext. 120