Utilization Management Nurse

Salary Range for Utilization Management Nurse in Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds

The salary range for a Utilization Management Nurse in the field of Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds typically falls between $60,000 and $90,000 per year.

Sample Job Description for Utilization Management Nurse in Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds Industry

Job Description:

As A Utilization Management Nurse In A Pharmacy Benefit Management And Other Third Party Administration Of Insurance And Pension Funds Company, Your Primary Objective Is To Ensure The Appropriate Utilization Of Healthcare Services And Resources. You Will Play A Crucial Role In Managing And Optimizing Healthcare Costs While Maintaining High-Quality Care For The Members Or Clients.

Job Requirements:

1. Bachelor'S Degree In Nursing (Bscn) Or An Equivalent Qualification. 2. Valid Registered Nurse (Rn) License. 3. Strong Understanding Of Medical Terminology, Diagnostic Procedures, And Treatment Options. 4. Familiarity With Healthcare Guidelines, Protocols, And Regulations. 5. Excellent Analytical And Problem-Solving Skills. 6. Ability To Review And Interpret Medical Records And Clinical Information. 7. Proficiency In Using Computer Systems And Healthcare Software Applications. 8. Strong Communication And Interpersonal Skills. 9. Attention To Detail And Ability To Work Independently. 10. Knowledge Of Insurance And Reimbursement Processes Is Preferred.

Job Responsibilities:

1. Review And Assess The Medical Necessity And Appropriateness Of Requested Healthcare Services. 2. Ensure The Utilization Of Healthcare Resources Aligns With Established Medical Guidelines And Policies. 3. Collaborate With Healthcare Providers To Develop Effective Treatment Plans And Alternatives When Necessary. 4. Evaluate And Authorize Pre-Authorization Requests For Medical Procedures, Surgeries, And Treatments. 5. Conduct Concurrent And Retrospective Reviews Of Medical Records To Ensure Compliance With Guidelines And Standards. 6. Identify Potential Cases Of Fraud, Waste, And Abuse And Report Them To The Appropriate Departments. 7. Communicate With Members, Providers, And Other Stakeholders Regarding Utilization Management Decisions And Processes. 8. Participate In Quality Improvement Initiatives To Enhance Healthcare Outcomes And Cost-Efficiency. 9. Stay Updated With Industry Trends, Regulations, And Advancements In Medical Practices. 10. Maintain Accurate Documentation And Records Of Utilization Management Activities.

Top 10 Employers for Utilization Management Nurse in Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds:

1. OptumRx - HQ Location: United States - Website: www.optumrx.com 2. Express Scripts - HQ Location: United States - Website: www.express-scripts.com 3. CVS Health - HQ Location: United States - Website: www.cvshealth.com 4. Cigna - HQ Location: United States - Website: www.cigna.com 5. Anthem, Inc. - HQ Location: United States - Website: www.antheminc.com 6. Aetna - HQ Location: United States - Website: www.aetna.com 7. Humana - HQ Location: United States - Website: www.humana.com 8. Magellan Health - HQ Location: United States - Website: www.magellanhealth.com 9. Prime Therapeutics - HQ Location: United States - Website: www.primetherapeutics.com 10. WellCare Health Plans - HQ Location: United States - Website: www.wellcare.com

Career Path for Utilization Management Nurse in Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds:

To become a Utilization Management Nurse in Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds, the typical career path involves the following positions and recommended years of experience in each role: 1. Registered Nurse (RN) - Recommended: 2-3 years 2. Clinical Nurse - Recommended: 3-5 years 3. Case Manager - Recommended: 3-5 years 4. Utilization Review Nurse - Recommended: 3-5 years 5. Utilization Management Nurse

Top 5 Countries by Utilization Management Nurse in Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds:

1. United States 2. Canada 3. United Kingdom 4. Australia 5. Germany

Top 5 Countries with Established Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds:

1. United States 2. Canada 3. United Kingdom 4. Germany 5. Australia