RN UM Discharge, Planning

Job Summary Collaborates with other health care providers to evaluate medical necessity of care for elective and emergency admissions, surgeries, diagnostic procedures and treatments. Coordinates the delivery of services in the most appropriate setting and supports transitions between settings for plan members, meeting organizational goals related to quality outcomes, member experience, and cost‑efficiency, using approved medical criteria and regulatory guidelines. Education & Experience Bachelor’s degree or four years of related experience. 3+ years in utilization management, utilization review, or care coordination with similar responsibilities. Registered Nurse license in good standing (preferred). CCM/ACM certification or equivalent helpful. Essential Functions Performs offsite or onsite admission, concurrent, or retrospective reviews for all levels of care (Inpatient Acute, LTAC, Rehabilitation, PHP, IOP, Skilled Nursing, Outpatient, Home Care). Responds to incoming calls and transmissions via Rockwell. Make accurate authorization determinations, collecting appropriate clinical information, applying medical criteria and consulting the Medical Director as per policy and procedure. Assist with arrangements for safe member transition between levels of care. Repatriates members from out-of-network or potential out-of-network settings to a network facility in a safe, timely, and cost‑effective manner. Maintains up‑to‑date work board of facility admission/discharge information for bed day reporting and timely claims payment; updates UM event status and labeling in case management information system. Identifies and refers at-risk members to SummaCare care and condition management programs. Receives, reviews, and routes incoming care management referrals to appropriate programs. Evaluates targeted members for use of appropriate in‑network providers and assists in gaining access to in‑network providers to achieve desired utilization and quality outcomes. Participates in organizational and health system quality improvement and program activities as assigned by supervisor. Maintains working knowledge of NCQA, SummaCare Board of Trustees and regulatory (CMS, State Department of Insurance) standards related to utilization and care management; consistently delivers services in compliance with these standards. Performs all job functions with integrity, providing timely internal and external customer service in a cooperative, professional, and respectful manner. Skills, Competencies and Other Qualifications Basic typing/computer skills needed to collect, assess, and enter data. Demonstrated knowledge and skills necessary to provide care appropriate to the age of the members serviced. Work cooperatively with team members to accomplish mission and goals. Organize and manage time to accurately complete tasks within designated time frames in a fast‑paced environment. Maintain current knowledge of and comply with regulatory and company policies & procedures. Maintain confidentiality of member health and business information. Flexible: Ability to adjust work hours to meet business demands. Effective interaction with populations of patients/customers with an understanding of their needs for self‑respect and dignity. Physical Demands Sit and/or stand for prolonged periods of time. Bend, stoop, and stretch. Lift up to 20 pounds. Manual dexterity to operate computer, phone, and standard office machines. Equal Opportunity Employer/Veterans/Disabled Salary: $34.00 – $50.99 per hour Benefits Basic Life and Accidental Death & Dismemberment (AD&D) Supplemental Life and AD&D Dependent Life Insurance Short-Term and Long-Term Disability Accident Insurance, Hospital Indemnity, and Critical Illness Retirement Savings Plan Flexible Spending Accounts – Healthcare and Dependent Care Employee Assistance Program (EAP) Identity Theft ProtectionPet Insurance Education Assistance Daily Pay #J-18808-Ljbffr