Nurse RN

In this role you will review inpatient stays and correctly apply the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. You will be assigned to members and review clinical information provided by facilities to determine medical necessity. You will also be involved with discharge planning and transfers as needed for higher levels of care or out of network admissions.

Responsibilities

• Perform prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members using Company and CMS evidenced based guidelines, policies and nationally recognized clinical criteria for the Company Medicare line of business.
• Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning.
• Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and members to be in compliance with state, federal and accreditation requirements.
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
• Identify potential quality of care issues, service, or treatment delays, and intervene as clinically appropriate.
• Refer to Case Management when there are acute inpatient needs affecting discharge.
• Attend staff meetings, clinical rounds, and weekly huddles.
• Maintain quality and productivity metrics for all casework.
• Maintain HIPAA compliant workspace for telework environment.

Requirements

• Associate’s degree in nursing required. Bachelor’s degree preferred.
• CA Nursing license required.
• Minimum of 5 years of experience in the inpatient hospital setting is required.

Skills

• Verbal communication skills, attention to detail, and problem-solving skills.
• Self-driven, able to work independently.
• Strong clinical background and critical thinking skills.
• Able to multitask while prioritizing cases to meet regulatory and business needs.

Pay

The typical base pay for this role across the U.S. is $44.00 - $46.00 per hour. Non-exempt positions are eligible for overtime at a rate of 1.5 times the base hourly rate for all hours worked in excess of 40 in a work week, or as required by state or local law.

Benefits

• Medical, dental, and vision benefits.
• Health savings accounts with qualified medical plan enrollment.
• 10 paid days off, 3 days paid bereavement leave.
• 401(k) plan participation with employer match.
• Life and disability insurance.
• Commuter benefits.
• Dependent care flexible spending account.
• Accident insurance, critical illness insurance, hospital indemnity insurance.
• Accommodations and reimbursement for work travel.
• Discretionary performance or recognition bonus.
• Sick leave and mobile phone reimbursement provided based on state or local law.