Utilization Review Nurse - Remote

American Health Plans Franklin, TN 37067, USA

Description American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Iowa, Idaho, Louisiana, and Indiana with planned expansion into other states in 2025. For more information, visit AmHealthPlans.com.

Benefits and Perks include:

Affordable Medical/Dental/Vision insurance options

Generous paid time-off program and paid holidays for full time staff

TeleDoc 24/7/365 access to doctors

Optional short- and long-term disability plans

Employee Assistance Plan (EAP)

401K retirement accounts with company match

Employee Referral Bonus Program

JOB SUMMARY:

The Utilization Review Nurse is to assess the medical necessity and quality of healthcare services by conducting pre-service, concurrent, and retrospective utilization management reviews. The primary role of the Utilization Management (UM) Nurse is to provide clinical support to the Clinical Services Department and Medical Director to assure that members receive all appropriate medical services in compliance with medical and regulatory guidelines.

ESSENTIAL JOB DUTIES:

To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.

Assess the medical necessity, quality of care, level of care and appropriateness of health care services for plan members

Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity

Conduct outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data

Apply clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided

Certify cases that meet clinical review criteria, guidelines and/or screensConvet

Consult with physician when reviews do not meet clinical review criteria, guidelines, and screens

Refer cases to other professionals internally, including case management and medical consultation when indicated

Adhere to accreditation, contractual and regulatory timeframes in performing all utilization management review processes

Ensure that the Director of Medical Management or designee is made aware of any potential risk management issues in a timely manner

Other duties as assigned

JOB REQUIREMENTS:

Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility

Encourage an atmosphere of optimism, warmth and interest in patients’ personal and health care needs

Develop and maintain collaborative relationships with providers and educate on levels of care

Ensure the integrity and high quality of utilization management services

Self-motivated

Ability to work independently and as part of a team

Able to work congenially with a wide variety of individuals

Maintain the highest level of confidentiality and professionalism at all times

Strong oral and written communications skills, including active listening

Proficient in navigating through multiple computer applications

Critical thinking and decision-making skills

Successful completion of required training

REQUIRED QUALIFICATIONS:

At least 1 year experience in utilization management with a health plan or hospital-based UM department with use of Interqual or MCG

Prefer clinical experience

Broad knowledge of Medicare regulations and guidance

Trained in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures

Strong knowledge of medical terminology and CPT, ICD-10, and HCPCS codes

Proven ability to problem-solve and make solid decisions

Current Certified Case Manager (CCM) credential is a plus

Current, active and unrestricted Registered Nurse (RN) license

This Organization is an equal opportunity employer. We do not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. This Organization will make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. A key part of this policy is to provide equal employment opportunity regarding all terms and conditions of employment and in all aspects of a person's relationship with the Organization including recruitment, hiring, promotions, upgrading positions, conditions of employment, compensation, training, benefits, transfers, discipline, and termination of employment.

Education Required Associates or better in Nursing.

Licenses & Certifications Required Registered Nurse

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

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