RN Care Management(Remote)

Utilization Management RN

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Come explore career opportunities with Liberty Health, a dynamic leader in the healthcare industry. UTILIZATION MANAGEMENT RN

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.

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.

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.

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

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

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.
• Excellent computer skills and the ability to learn new systems are required.
• Demonstrated ability to problem-solve and manage professional relationships.
• Healthcare industry knowledge
• High level of professionalism and confidentiality, with a strong customer focus.
• Clearly communicates instructions to remote users.