RN Coordinator Utilization Management

Job Responsibilities

• Evaluate and process prior authorization requests/referrals submitted from contracted and non-contracted providers
• Follow Network Health process, policies, and procedures in authorization review of all membership on a pre-service, concurrent and post-service basis
• Verify eligibility and benefits, as well as document all utilization management communication
• Provide education regarding utilization management activities and processes to members, caregivers, providers, and their administrative staff
• Participate in Utilization Management auditing (e.g., Utilization Management Inter-reviewer reliability and denial files)
• Refer all members with complex health problems and needs to Network Health Case Management to reduce medical costs while providing a higher quality of life and an ability to take charge of their diseases
• Collaborate with other NH departments to develop interdepartmental operational processes
• Support Utilization Management department programs and goals through active participation
• Identify and screen candidates for Case Management intervention and determine appropriate level of care from Utilization Management criteria
• Complete assessments and plans of care including need for medication regime, treatment plans, practitioner follow-up appointments, knowledge of red flags, disease management, Advance Directives, life planning, and self-management of illness to the best of member ability
• Evaluate cases for cost savings/quality improvement potential

Job Requirements

• Bachelor of Science in Nursing, preferred
• Associate Degree in Nursing, required
• Current registered nurse licensure in Wisconsin required
• Minimum of four (4) years clinical health care experience as a Registered Nurse (RN) required
• Experience in insurance, managed care and utilization management preferred