Utilization Management Nurse

UTILIZATION MANAGEMENT RN Job Summary: Day-to-day management of Utilization Management queues, dashboards, members, ensuring all Utilization Management activities—including authorization timeliness, discharge planning, and adherence to policies/procedures to ensure high quality and cost-effective utilization management services. Carry out 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 reports to be reviewed by Executive Leadership. Contribute to the UM team to ensure compliant execution of the UM program. Review admissions and service requests for authorization requests to ensure appropriate care for members within clinical guidelines, monitor members inpatient/outpatient, provide updates to Director and clinical care teams, and recommend more appropriate care if required. Assess and coordinate discharge planning with Care Team. Assist co-workers with coding, medical records/documentation, pre-certification reimbursement and claim denials/appeals. Use critical thinking and problem-solving to navigate the complexities of a member’s health conditions while maintaining coverage within program guidelines. Focus on interventions for improvement. Provide appropriate responses to providers regarding UM questions or direct these questions to the Director. Monitor utilization management queues and dashboards, assuring compliance with reporting and turnaround times. Participate in interdisciplinary approach to support continuity of care. Participate in Case Management processes and assist with development of case management programs. Contribute to written policies and procedures and workflows. Participate in the On-Call rotation to ensure timeliness is maintained. 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 of 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. Strong attention to detail, organizational skills, and interpersonal skills. 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. Adapt well to operational needs with excellent follow-up skills. Self-motivated, with a work ethic of dedication and the discipline to work independently. Valid driver’s license. Proven ability to communicate concisely and confidently with all staff levels and to clearly communicate instructions to remote users. Background checks/drug-free workplace. EOE. #J-18808-Ljbffr