Registered Nurse (RN) - Utilization Management

As a Registered Nurse (RN) specializing in Utilization Management at Spectrum Healthcare Resources, your primary responsibilities include reviewing and determining the appropriateness of beneficiary care, conducting assessments for pre-authorizations and continued stay reviews, and documenting findings in the medical management information system. Additionally, you will present complex cases to the Medical Director and advise non-clinical staff on clinical and coding questions.

To qualify for the Registered Nurse Utilization Manager position at Spectrum Healthcare Resources, candidates must hold either an ADN or BSN degree, possess an active RN license in any state, and have at least 2 years of clinical and utilization management RN experience. It's preferred to have worked with Healthnet Federal Services or Tricare and to be able to pass a Department of Defense background investigation or hold a security clearance.

The work schedule for the RN Utilization Manager position at Spectrum Healthcare Resources is Monday through Friday from 8 AM to 5 PM PST. This predictable schedule allows for a work-life balance while fully engaging with your responsibilities from a remote setting.

While prior experience with Healthnet Federal Services or Tricare is preferred for the RN Utilization Manager role at Spectrum Healthcare Resources, it is not strictly necessary. Candidates with 2+ years of relevant clinical and utilization management experience will also be considered competitively for this remote nursing position.

Yes, the Registered Nurse (RN) - Utilization Management position at Spectrum Healthcare Resources is entirely remote. Nurses can work from home while effectively performing their responsibilities, offering flexibility and convenience.

When answering this question, highlight specific experiences where you've assessed patient care plans, conducted reviews, and helped manage healthcare costs. Be prepared to share examples of the challenges you faced and how you effectively addressed them to improve patient outcomes.

Discuss your systematic approach to pre-authorization requests, including how you ensure thorough clinical assessments and use evidence-based criteria to determine medical necessity. Emphasize your collaboration with healthcare teams and communication skills when following up on authorizations.

For this question, you should articulate your method for identifying complex cases, as well as how you prepare documentation and data for presentation to the Medical Director. Detail your understanding of interdisciplinary teamwork, ensuring all pertinent information is conveyed clearly.

Be sure to mention clinical criteria, the appropriateness of care, and associated costs as key indicators in your review process. Your answer should reflect your analytical skills and ability to make decisions based on comprehensive evaluations.

Describe your proactive approach to continuous education, such as attending workshops, reading relevant journals, and participating in professional organizations that focus on utilization management. Show your commitment to maintaining up-to-date knowledge to best serve patients.

Highlight how your experience in case management has provided a broader understanding of patient care continuity and resource allocation. Discuss how these insights help you make informed decisions when advocating for patients and managing resources more efficiently.

Discuss the importance of clear communication with both clinical and non-clinical staff to ensure everyone understands care requirements and restrictions. Explain how strong communication contributes to optimal patient outcomes and resource management.

Explain your familiarity with coding guidelines and how you use this knowledge to address coding inquiries. Emphasize your collaboration with coding specialists to ensure accuracy and compliance in documentation.

Detail your systematic process for conducting pre-admission screenings, including patient interviews, chart reviews, and any specific criteria that guide your assessments to determine medical necessity and appropriateness of care.

Describe your conflict resolution skills, emphasizing your ability to listen actively, present evidence-based rationale, and maintain a patient-centric approach while advocating for the best solutions among conflicting opinions.