Contract Utilization Management Nurse

Responsibilities

• Rigorous adherence to PACE program service authorization policies, ensuring that participant care and related claims are: Reasonable and necessary for diagnosis or treatment and consistent with PCP coordination decisions.
• In accordance with accepted medical standards and consistent with the participant care needs including level of care and advanced care planning principles.
• Active involvement in various aspects of the utilization management process, including:
• Concurrent review of all hospital admissions (observation and inpatient) with the Interdisciplinary Team driving efficient and timely transitions of care,
• Retrospective review of inpatient admissions under 48 hours,
• Claims submitted inconsistent with the service authorization.
• Congurrent review of all subacute and SNF admissions with the Interdisciplinary Team driving efficient and timely discharge plans and transitions of care.
• Coordination and review of all other services delivered by contracted providers and identified by the PACE program assuring consistency with Interdisciplinary Team service authorization, care plans, and PCP coordination decisions.
• Employ effective use of knowledge, critical thinking, and skills to:
• Advocate quality care and enhanced quality of life,
• Advocate decreased hospital stay when appropriate,
• Maintain accurate records of all patient related interactions,
• Appeal Management - In cases of claim rejection, the IntusCare Utilization Management Nurse will lead the provider appeals process.
• Responsibilities Include:
• Comprehensive review of provider network appeals.
• Collaboration with the PACE Program's Medical Director to review and respond to appeal requests, ensuring issuance of a written determination consistent with the PACE program policies.

Qualifications

• 3 to 5 years of utilization management experience.
• Current RN license
• Proven experience working in risk based integrated models of care.
• Ability to use data to drive decisions and collaboration with internal and external stakeholders.
• Strong strategic thinking, problem solving, and decision making skills.
• Excellent communication and leadership abilities, capable of motivating and guiding teams toward timely and efficient care management strategies

Pay

The range for this role is $42.00/Hour.