McLaren Health Plan (MHP) is a company with a culture of high performance and a mission to help people live healthier and more satisfying lives.  We are looking for a Utilization Management RN, to join in leading the organization forward.

MHP is a Managed Care Organization dedicated to meeting the health care needs of each member. MHP offers multiple product lines, including individual and family plans, and Medicaid and Medicare plans to Michigan residents for every stage of life. McLaren Health Plan is accredited by the National Committee for Quality Assurance (NCQA).

MHP values the talents and abilities of all our employees and seeks to foster an open, cooperative and dynamic environment in which employees and the health plan can thrive. As an employee of MHP, you will be a part of a dynamic organization that considers all our employees as leaders in driving the organization forward and delivering quality service to all our members.

Position Summary:

This position is responsible for utilization management functions.  This includes but is not limited to review and authorization of services, utilization of medical policy, utilization of standard screening techniques, and utilization of behavioral change techniques.  Works with the PCP, the member and management to promote the delivery of quality services at the most appropriate and cost-effective setting. Performs as the member advocate with emphasis on education regarding managed care, disease management and PCP treatment plans. Monitors member’s utilization patterns for identification of high risk, and under and overuse of services. Collaborates with Medical Director and senior management on complex cases and special projects.

#LI-KH1

Qualifications:

Required:

• RN with a valid unrestrictive license from state employed in state providing services.
• Two (2) years clinical nursing experience.

• One (1) year previous experience in Managed Care Utilization Management, Medical Management, Case Management.

 Preferred:

• Two (2) years’ experience and knowledge of HMO, PPO, TPA, PHO and Managed Care functions including understanding of claims  administration, including CPT-4 codes, revenue codes, HCPCS codes, DRGs, etc.

• Two (2) years’ experience in Managed Care Utilization Management, Medical Management, Case Management.

• BSN.

• Certified Case Manager