UTILIZATION MANAGEMENT RN

Utilization Management RN

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We are currently seeking an experienced:

UTILIZATION MANAGEMENT RN

JOB SUMMARY:

Day-to-day management of Utilization Management queues, dashboards, members, ensuring all Utilization Management activities, which include authorization timeliness, discharge planning, adherence to policies and procedures to ensure high quality and cost-effective utilization management services.

Ability to work decision letters timely and accurately

Quality monitoring focusing on medical necessity guidelines and discharge planning opportunities to lower levels of care

Assist the Director of Utilization Management with the Utilization Management Reports to be reviewed by Executive Leadership.

Ability to contribute to the UM team to ensure compliant execution of UM program

Review admissions and service requests for the following:

• Authorization requests to ensure appropriate care for members and within clinical guidelines
• Monitor members both inpatient/outpatient – provide updates to Director of Utilization Management and the clinical care teams
• Recommend more appropriate care if required

Assess and coordinate discharge planning with Care Team.

Assist co-workers with issues related to coding, medical records/documentation, pre-certification reimbursement and claim denials/appeals.

Use critical thinking and problem-solving to navigate through the complexities of a member's health conditions while maintaining coverage within the program guidelines.

Ability to focus on interventions for improvement

Provides appropriate responses to providers regarding UM questions or direct these questions to the Director of Utilization Management

Monitors utilization management queues and dashboards, assuring compliance with reporting and turnaround times.

Participates in the interdisciplinary approach to support continuity of care

Participates in the Case Management processes and assists with the development of case management programs

Ability to participate and contribute with the written policies and procedures and workflows

Ability to participate in the On-Call rotation to ensure timeliness is maintained

Ability to work occasional after hours to ensure timeliness is maintained.

Contribute to and attend UM meetings and UM huddles.

Other duties as assigned

Less than 10% travel to the corporate office for Department meetings

JOB REQUIREMENTS:

• Licensed Registered Nurse credentialed from an accredited school/college with 3–5 years of clinical experience
• Maintain Active Registered Nurse License, (Compact, RN preferred)
• 1–5 years managed care Utilization Management experience (preferably with a Health Plan)
• Demonstrated experience in health plan utilization management, initial reviews, facility concurrent review discharge planning, and case management required.
• Medicare Advantage experience required
• Experience with InterQual or MCG authorization criteria preferred.
• Excellent computer skills and the ability to learn new systems are required.
• Strong attention to detail, organizational skills, and interpersonal skills are required.
• Demonstrated ability to problem-solve and manage professional relationships.
• Healthcare industry knowledge
• Excellent listening, verbal, written and interpersonal communication skills.
• High level of professionalism and confidentiality, with a strong customer focus.
• Can adapt well to operational needs with excellent follow-up skills.
• Must be self-motivated, with a work ethic of dedication and the discipline to work independently.
• Must have a valid driver's license.
• Proven ability to communicate concisely and confidently with all staff levels. Clearly communicates instructions to remote users.

Visit for more information. Background checks/drug-free workplace. EOE.