Utilization Management RN - Jefferson Health Plan

Utilization Management Nurse The Utilization Management Nurse is responsible for assuring cost effective, quality utilization management in the acute level of care setting for the pediatric or adult population in the post-acute inpatient setting (i.e., SNF/Rehab). Also, responsible to review clinical information provided by facilities and communicates UM determinations maintaining timeliness. Work under general supervision of manager and team lead to assure cost-effective, quality patient care management for DME, homecare (acute skilled nursing and therapy services), home infusion, hospice at home, transportation, and Shift care (private duty home health for pediatric medically complex members). Job Description Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson. Review and track emergency admissions to identify appropriate level of care for acute and post-acute inpatient services. Perform concurrent review and/or admission review on all hospital admissions using InterQual criteria guidelines. Track assigned cases for timely reviews/updates and decisions as reflected in case documentation. Request and review medical records to identify appropriate acute care days and approve or refer questionable days to the medical director for decision. Function as a liaison between providers, members and interdepartmentally. Serve as resource for physicians, PCPs, Utilization Review departments and all medical providers. Identify trends that impact on utilization at hospitals during the review process and help resolve them. Maintain departmental and regulatory timeframes for utilization decisions. Contributes to the development and enhancement of documentation, tracking tools and process flows Maintains collaborative and effective cross- functional training within the Utilization Management Department Utilization management perform after hour's on-call coverage. Participates in relevant work groups and provide deliverables as necessary Successful and timely completion of assignments in accordance with departmental and Company operational objectives and seeks feedback on performance. Ensures that assignments are scheduled and completed in an accurate and timely manner. Maintains detailed knowledge of the status of all assignments and routinely updates the manager, as appropriate Responsible to for after hour on call shifts as needed Performs all other duties as assigned Education and Experience: Graduate of an accredited nursing program (Associate's or Bachelor's degree in Nursing). BSN preferred. Minimum of 2-3 years of clinical nursing experience. At least 1 year of utilization management, case management, or managed care experience preferred. Work Shift: Workday Day (United States of America) Worker Sub Type: Regular Employee Entity: Health Partners Plans, Inc. Primary Location Address: 1101 Market, Philadelphia, Pennsylvania, United States of America