UM Clinical Specialist RN - Physical Health (Full Time,...

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 & DutiesAssesses the medical necessity of servicesIndependently conduct medical necessity reviews of service requests submitted by service providers against developed clinical guidelines within contractually mandated turn-around timesEnsure authorized services address appropriate service needs, intensity of service outcomes, and alternatives for consumersProvide a consistent application of medical necessity criteria for physical health services that promotes a holistic review of the member's needsConduct pre-certification, concurrent, and retrospective reviews to ensure compliance with medical policy, member eligibility, benefits, and contractsConduct utilization reviews to monitor adherence to clinical practice guidelines and best practice standardsNotify members of adverse benefit determinations while preserving members' Due Process rightsEnsure compliance with performance measures outlined within all accrediting body standardsPerform other related duties as required by the immediate supervisor or other designated Alliance Health administratorsComplianceComply with utilization management and quality improvement policies and procedures, utilization review laws and regulations, state standardsComply with Utilization Management Department focus on timeliness, effectiveness, quantity, quality, and cost of services for eligible enrolleesCoordinate and Implement UM ProcessesParticipate in the integration of the department and its functions into the organization's primary missionTake part in the Utilization Management Department collaboration to ensure an integrated department with Physical Health and Behavioral HealthCollaborate with other departmentsMonitor for undesirable performance or deviations of practice standards that may have a negative impact on consumers. Respond through additional follow-up with consumer and providers, provider technical assistance and/or referral to other departments within the MCO. Maintain open, timely communication with staff, providers, community agencies and other stakeholdersMinimum RequirementsEducation & ExperienceGraduation from a State accredited school of nursing or an Associate's Degree in Nursing from an accredited and five years of experience with five (5) years nursing experience ORBachelor's degree in Nursing from an accredited college/university and three (3) years of nursing experienceSpecial RequirementCurrent, active, and unrestricted North Carolina clinical license as a Registered Nurse, or a compact licensePreferred Experience:Experience in Utilization Management Knowledge, Skills, & AbilitiesKnowledge of physical health and co-morbid health conditionsKnowledge of diagnostic treatment guidelines/protocols, level of care criteriaProficient in the use of computer and multiple software programs.Written and oral communication skillsAbility to interact with a wide variety of individuals and handle complex and confidential sensitive situations.Knowledge of Utilization Management managed care principles and strategiesAbility to analyze effectiveness of processes and adjust developed processes.Knowledge of and experience in acute clinical utilization reviewKnowledge of Authorization/re-authorization Utilization Management standardsKnowledge of related duties in the delivery of patient care, management of patient care providers, or project management in a healthcare environmentAbility to lead, delegate and problem solveAbility to develop and document workflowsAbility to assist appeal efforts when medical care is denied by various payor entities in a timely fashion.Knowledge of and experience with NCQA Salary Range $68,227 - $86,990/Annual Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity. An excellent fringe benefit package accompanies the salary, which includes: Medical, Dental, Vision, Life, Long Term DisabilityGenerous retirement savings planFlexible work schedules including hybrid/remote optionsPaid time off including vacation, sick leave, holiday, management leaveDress flexibility Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

Created: 2026-04-15