UTILIZATION MANAGEMENT RN

Job Summary

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.

Responsibilities

• Ability to work 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 the Utilization Management Reports to be reviewed by Executive Leadership
• Ability to contribute to the UM team to ensure compliant execution of UM program
• Review admissions and service requests for the following: 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
• Ability to focus on interventions for improvement
• 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
• Ability to 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

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 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 are required
• Strong attention to detail, organizational skills, and interpersonal skills are required
• 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
• Can adapt well to operational needs with excellent follow-up skills
• Must be self-motivated, with a work ethic of dedication and the discipline to work independently
• Must have a valid driver’s license
• Proven ability to communicate concisely and confidently with all staff levels
• Clearly communicates instructions to remote users