Utilization Management Nurse

Utilization Management Nurse

Under the supervision of the Health Services Director, the Utilization Management Nurse (LPN or RN) uses a multidisciplinary approach to organize, coordinate, monitor, evaluate, create and manage organization determinations and authorizations. These service requests will focus on selected complex medical and psychosocial needs of Solis Health Plans members. The UM Nurse is responsible for assuring the receipt of high quality, cost efficient medical outcomes for enrollees. This role works with Medical Directors, Authorization Coordinators and Service Coordinators to perform first level review to pre-certify elective services, procedures and tests utilizing established Care Coordination polices and protocols, Solis Health Plans benefit criteria, applicable regulatory review criteria and nationally accepted criteria for medical necessity determination.

Main Key Responsibilities:

• Conduct concurrent and retrospective utilization review for inpatient, observation or SNF services.
• Conducts clinical reviews of proposed services against appropriate criteria/guidelines to determine medical necessity, benefit eligibility, and network contract status.
• Work with Medical Directors, Program Leadership and Solis Health Plans Provider Relations Teams to identify and mitigate facility barriers associated with the ability to make timely decisions.
• Identify, align and utilize health plan and community resources that impact high-risk/high cost care.
• Act as liaison between assigned facilities, members/families, and Solis Health Plans. Clarify policies/procedures and member benefits as needed. Authorizes services, coordinates care, and ensures timeliness and coordination of healthcare services, in compliance with department and regulatory standards, seeking supplemental services when appropriate or when needed.
• Assess enrollee needs and monitor progress toward goals at all times, communicating findings and status with members of the enrollee's primary care team.
• Ensure optimal delivery of safe quality health care to members, while maximizing resources and containing costs, and facilitate continual patient-centered and outcome-driven health performance improvement activities.
• Review enrollees with the Medical Directors and Primary Care Teams and advocates for Administration Exception considerations as appropriate.
• Facilitate communications between the facility, providers, and the PCT in order to effect and influence a safe and effective discharge plan and care plan for the enrollee.

Qualifications:

• Graduate from an accredited school of nursing, or Bachelors (or advanced) degree in nursing.
• Active and unrestricted licensure as a Registered Nurse in Florida.
• A minimum of three to five years clinical experience as a Registered Nurse in a clinical setting required.
• 2 years' experience as a Utilization Management nurse in a managed care payer preferred.
• One year experience as a case manager in a payer or facility setting highly preferred.
• Discharge planning experience highly preferred.

Work Conditions:

• The noise level in the work environment is usually moderate.
• Fast-paced office environment.
• Highly regulated environment.
• Time frames to handle issues are in accordance with CMS time frames.

This work requires the following physical activities: climbing, bending, stooping, kneeling, twisting, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Performance Measurements:

• Duties accomplished at the end of the day/month
• Compliance with Department Call Metrics/ Company Regulations
• Attendance/Punctuality
• Safety and Security
• Accuracy Rate

This Job Description may be modified at any time at the discretion of the employer as business operation may seem necessary. This does not constitute an employment agreement and may not include all duties. The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate.

Solis Health Plans provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Employee Acknowledgement: I have read this job description and understand what is expected of me while I occupy this role.