Alliance Health
Morrisville, NC, USA
The Utilization Management (UM) Clinical Specialist RN for physical health (PH) independently assesses the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, and out of network services, monitors consumer treatment through ongoing and continuous review to ensure that services are delivered based on consumer need and established clinical guidelines, and identifies and follows-up on clinical cases of concern and high-risk/special needs consumers to ensure enrollees are linked to appropriate treatment resources. The UM Clinical Specialist RN - PH may represent the unit in cross agency collaborative needs.
This position will allow the successful candidate to work a schedule that will be primarily remote. While there is no expectation of being in the office routinely, they will be required to come into the Alliance Office for business and team meetings as needed.
Responsibilities & Duties
Assesses the medical...