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Job Discription
Prairie States Enterprises, Inc. is a third party administrator, a benefits industry leader, and a trusted advisor to self-insured companies and their employees. We provide a complete range of medical benefit management services, all performed in-house, and to exacting standards of excellence by our professional staff.
We are seeking an experienced Utilization Management Registered Nurse who is looking to contribute to healthcare as part of our Clinical & Health Services Team. As a supportive role to the Vice President of Clinical & Health Services, the Utilization Management Registered Nurse is responsible for the utilization management/review of claimants from Prairie States Enterprise’s book of business.
This is a full-time position with a hybrid remote work arrangement in our Sheboygan, WI location.
Highlights of Essential Job Functions:
- Claim reviews: Pre-Claim, Concurrent Claim, and Post-Claim Reviews (Retro Reviews) as identified by claims analyst, bill audit staff, or Health Management
- Responsible for UM-RN function of designated groups.
- Reviews and contacts Clinical staff at the Provider for medical information to ensure the completeness of the medical record.
- Researches Plan language in the Employer Benefit Plan Document, and makes a clinical determination of coverage or no coverage.
- Coordinates the sending of cases out for medical review if required.
- Responsible for the authorization of services or denial of services based on the Employer Benefit Plan Document. Subsequently also handles all appeals.
- Assists with maintaining Quick Reference Guide for designated groups
- Stop Loss Reporting:
- Notify Case Manager of potential need for CM as appropriate
- Vacation and Overflow coverage for standard Pre-certification and Utilization Management staff
- Assists with writing and updating Policies and or Procedures related to the UM function
Position Requirements:
- BSN Required; RN current licensure in good standing
- Minimum of 5 years of clinical experience
- Past UM or CM experience in clinical or hospital setting desirable
- Strong competence in the use and understanding of the MCG guidelines for medical necessity
- Strong competence with patient care management systems
- Proficient Computer Skills: Word, Excel, Microsoft Outlook, keyboarding and data entry
Required Competencies:
- Change Management – Accepts, supports, and executes assignments in conditions of change which support attaining department goals.
- Effective Communication – Demonstrates effective and responsive communications following the appropriate reporting structure.
- Accountability/Results – Achieves and/or exceeds result based goals that were specific, measurable, and timely.
- Teamwork – Demonstrates teamwork behaviors and makes positive contributions and which support the achievement of department goals.
- Customer Satisfaction – Dedicated to the PSE service model and meets or exceeds PSE customer satisfaction expectations in providing exemplary service.
- Professional Growth – Takes ownership of one’s professional growth within one’s current position and to advancement at PSE.
To the selected candidate, we offer:
- Competitive compensation based on experience and a comprehensive benefit package provided to include Medical, Dental, Vision, Life, STD/LTD, FSA, Paid Time Off, personal days, 401k with match, wellness and exercise membership and more. Click HERE to view our full-time benefits flyer.
- Opportunity for meaningful career growth within a results-driven company and our company culture is one of ambition, integrity, empowerment, teamwork and a passion for personal and company success.
If this sounds like you and you’re seeking career growth with an exciting new career path in overseeing the quality of health care for our clients and their members, please send your cover letter and resume following the instructions for this site.
Prairie States Enterprises
Equal Opportunity Employer
