Position Summary

Provides comprehensive medical management services including utilization management, education, recommendations, hospital notification, and health care cost projections for a select group of clients. Performs services within the scope of licensure for individuals with complex and chronic care needs by assessing, planning, facilitating, advocating, and monitoring services designed to optimize patient health care across the care continuum. Ensures patient satisfaction and access to services appropriate to meet health care needs.

What will your job entail?

Job Responsibilities:

• Performs all utilization review functions within the scope of licensure.
• Conducts comprehensive utilization review with members as identified by evidence-based guidelines and specific account plan language.
• Provides timely follow up, monitoring, advocacy, referral, discharge and transition coordination in accordance evidence-based guidelines and account benefit structure.
• Interfaces with the Medical Director/Consultants and/or the Vice President as clinically indicated.
• Completes all license related requirements including continuing education.
• Performs utilization review associated administrative functions including, but not limited to, data entry, written correspondence, written reports, negotiating rates, and billing documentation.
• Maintains a positive working relationship with all CMSI clients/members while promoting a positive image for CMSI within the healthcare community.
• Works collaboratively toward all CMSI identified quality improvement goals.
• Knowledge of patient care charts, patient histories and principles, procedures, methods and techniques of nursing and health care; review of medical records; basic coding information
• Knowledge of components of the utilization review process including, but not limited to, assessment, education, care planning, advocacy, monitoring, and transition coordination.
• Basic knowledge of industry evidence-based guidelines/criteria
• Knowledge of and adherence to HIPAA privacy and security guidelines
• Knowledge of and adherence to Diversity and Inclusion guidelines
• Strong oral, written, and interpersonal communication skills.
• Ability to work within a multidisciplinary team (internally and externally) as well as independently.
• Proficient computer skills including keyboarding, data application entry, Word, and Excel
• Basic math skills including use of a calculator, addition, subtraction, multiplication, division, percentages. Ability to read graphs and work with monetary units.
• Other duties as assigned.

Work Experience and Education:

• 3 years or more of direct clinical experience (i.e. acute care, home health care, skilled nursing facility)
• Experience in utilization management and/or disease management preferred.
• 2 years or more of Utilization Management experience with CMSI or previous experience
• Participates in ongoing Utilization Management education per specialty

Licenses and Certifications:

• Prescribed: Active unrestricted Registered Nurse (RN), Licensed Practical Nurse (LPN), Physical Therapist (PT) or Social Work (SW) license in the state of WI
• Preferred: Multi-state license preferred.

Ryan Specialty is an Equal Opportunity Employer. We are committed to building and sustaining a diverse workforce throughout the organization. Our vision is an inclusive and equitable workplace where all employees are valued for and evaluated on their performance and contributions. Differences in race, creed, color, religious beliefs, physical or mental capabilities, gender identity or expression, sexual orientation, and many other characteristics bring together varied perspectives and add value to the service we provide our clients, trading partners, and communities. This policy extends to all aspects of our employment practices, including but not limited to, recruiting, hiring, discipline, firing, promoting, transferring, compensation, benefits, training, leaves of absence, and other terms, conditions, and benefits of employment.

How We Support Our Teammates

Ryan Specialty seeks to offer our employees a comprehensive and best-in-class benefits package that helps them — and their family members — achieve their physical, financial, and emotional well-being goals. In addition to paid time off for company holidays, vacation, sick and personal days, Ryan offers paid parental leave, mental health services and more.

The target hourly rate range for this position is $36.00 - $46.00 per hour.

The wage range for this role considers many factors, such as training, transferable skills, work experience, licensure and certification, business needs, and market demands. The pay range is subject to change and may be modified in the future. Full-time roles are eligible for bonuses and benefits. For additional information on Ryan Specialty Total Rewards, visit our website https://benefits.ryansg.com/.

We provide individuals with disabilities reasonable accommodations to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment in accordance with applicable law. Please contact us to request an accommodation at HR@Ryansg.com

The above is intended to describe this job's general requirements. It is not to be construed as an exhaustive statement of duties, responsibilities, or physical requirements. Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.