Utilization Management Professional (RN)

Phoenix, AZ 85034

Posted: 04/19/2019 Job Number: 26716


  • Under general supervision, and in collaboration with Medical Directors and other members of the clinical team, gathers and synthesizes clinical information in order to authorize services.
  • Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria; collects and analyzes utilization information; assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity.
  • Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria.


  • Develops and manages new enrollee transitions and those involving a change in provider relationships.
  • Develops and implements transition plans, as indicated, to ensure continuity of care.
  • Negotiates and documents single case agreements according to the company' s procedures.
  • Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria.
  • Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network.
  • As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.
  • In conjunction with providers and facilities, identifies, develops and monitors discharge plans.
  • Collaborates with the Care Coordination Team to implement support for discharge planning and transitions in care.
  • Facilitates timely sharing of enrollees clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.
  • Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria.
  • Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases.
  • Assures that case documentation for each decision is complete, including related correspondence and within required contractual timelines.
  • Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.
  • Maintains an active work load in accordance with performance standards. - Works with community agencies as appropriate.
  • Participates in network development including identification and recruitment of quality providers as needed.
  • Advocates for the enrollee to ensure health care needs are met. Interacts with providers in a professional, respectful manner.
  • Provides coverage of Nurse Line and/or Crisis Line as requested or required for position.


HOURS: Monday – Friday 8AM – 5PM

  • RN required
  • 3 years’ experience post degree in a clinical, medical, psychiatric and/or substance abuse health care setting.
  • Also requires minimum of 3 years of experience conducting utilization management according to medical necessity criteria.
  • Health Plan experience preferred
  • Knowledge of AHCCCS a plus
  • Must have advanced computer skills to include the use of Microsoft products and medical management systems

EDUCATION: Associate’ s Degree Minimum
  • InterQual experience required
  • Inpatient experience required

Please Contact:

Katherine Skelton

877-782-3334, EXT 246


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