We are looking for a Utilization Management, RN - IN to join us in leading our organization forward.
McLaren Integrated HMO Group (MIG), a division of McLaren Health Care Corporation, is an organization with a culture of high performance and a mission to help people live healthier and more satisfying lives.
McLaren Health Plan and MDwise, Inc., subsidiaries of MIG, value the talents and abilities of all our employees and seeks to foster an open, cooperative and dynamic environment in which employees and the health plans can thrive. As an employee MIG,you will be a part of a dynamic organization that considers all our employees as leaders in driving the organization forward and delivering quality service to all our members.
McLaren Health Plan is our Michigan-based health plan dedicated to meeting the health care needs of each of our Michigan members. Learn more about McLaren Health Plan at https://www.mclarenhealthplan.org
MDwise is our Indiana-based health plan, working with the State of Indiana and Centers for Medicare and Medicaid Services to bring you the Hoosier Healthwise and Healthy Indiana Plan health insurance programs.Learn more about MDwise, Inc. at https://www.mdwise.org/
Position Summary:
This position is responsible for utilization management functions.This includes but is not limited toreviewandauthorizationofservices, utilization of medical policy, utilization of standard screening techniques, and utilization of behavioral change techniques.Works with the PCP, the member and managementtopromotethedeliveryofqualityservicesatthemostappropriateand cost-effectivesetting. Performs as the member advocate with emphasis on education regarding managed care, disease management and PCP treatment plans. Monitors member’s utilization patterns for identification of high risk, and under and overuse of services. Collaborates with Medical Director and senior management on complex cases and special projects.
This is a fully remote position.
Equal Opportunity Employer of Minorities/Females/Disabled/Veterans
Qualifications: Required :
RNwithavalidunrestrictivelicensefromstateemployed in state providing services.
Two(2)yearsclinicalnursing experience.
One (1) year previous experience in Managed Care Utilization Management, Medical Management, Case Management.
Preferred:
Two (2) years’ experience and knowledge of HMO, PPO, TPA, PHO and Managed Care functions including understanding of claims administration, including CPT-4 codes, revenue codes, HCPCS codes, DRGs, etc.