Utilization Management RN

Job Title

Completion of an accredited registered nursing (RN) degree program is required. Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice is required. Minimum of three (3) years clinical experience is required.

Nice to Have Skills & Experience:

• Med/surgical, emergency acute clinical care or home health experience is preferred
• Utilization Management/Utilization Review experience is preferred
• Medicaid/Medicare/Commercial experience is preferred

Job Description:

Responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members enrolled with a CareSource Management Group line of business, as well as monitoring the delivery of healthcare services in a cost effective manner.

Essential Functions:

• Complete prospective, concurrent and retrospective review of acute inpatient admissions, post acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment
• Coordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective manner
• Refer cases to CareSource Medical Directors when clinical criteria is not met or case conference is needed/appropriate
• Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards
• Identify and refer quality issues to Quality Improvement
• Identify and refer appropriate members for Care Management
• Document, identify and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care
• Provide guidance to non-clinical medical management staff
• Provide guidance to and assist with oversight of LPN medical management staff
• Attend medical advisement and State Hearing meetings, as requested
• Assist Team Leader with special projects or research, as requested
• Perform any other job-related instructions, as requested