Utilization Management Nurse I

As a Utilization Management (UM) Nurse, you will provide UM services which includes transition of care and support to members and health care providers. You will be utilizing clinical knowledge and expertise will to interpret and appropriately apply medical policy, medical necessity criteria (InterQual), and benefit information to provide consultation and responses to UM requests. You will proactively assess and assist members to help move them through the continuum of care by utilizing services and resources efficiently. Also as a member of a multidisciplinary team, you will be continuously looking for ways to improve processes and maximize health dollars for our members. This will also require processing utilization management requests by utilizing clinical knowledge and expertise in interpreting medical policy, medical criteria (InterQual), and benefit information for internal and external customers within the timeframes described in the requirements. Furthermore, interacting with Wellmark Medical Directors and Physician Reviewers, as appropriate for services that do not meet medical criteria.