Utilization Management RN

About the role

Utilization Management (UM) nurses will provide appropriate and comprehensive utilization of health care services and benefits as designated. This role requires an experienced RN with a diverse clinical background, as well as experience within the managed care industry and specifically in the self-funded arena.

Responsibilities

• Work with providers, hospitals, members and clients to achieve optimal outcomes through appropriate use of services and benefits.
• Pre-Certification of emergency, urgent and elective admissions, and the determination of length of stay based on age, multiple or single diagnoses, and the nature of the diagnosis.
• Medical record review to determine medical necessity of requested services.
• Concurrent review and the determination of the extension of the length of stay based on the severity of illness and the intensity of service.
• Aid in Discharge Planning to ensure compliance with benefit plan and use of preferred providers/networks.
• Steerage to high quality, cost-effective domestic and in-network providers.
• Identification of alternative treatment plans, which are to be approved by all parties.
• Establishing identification of services, resources, providers and facilities that could best serve clientele in a timely and cost-effective manner in order to obtain optimum value for the client and reimbursement source.
• Interpret individual health plans and authorize/coordinate care in accordance with plan provisions.
• Evaluate the cost effectiveness of the elected treatment plan, pre-implementation and post-implementation.
• This outcome measurement will be used in determining the effective results and in establishing future patient-centered care plans.
• Referral to appropriate care management resources (i.e. Medical Director, Complex Case Management, and Chronic Condition Management teams).

Qualifications

• 5+ years related work experience.
• Professional background in clinical nursing and patient assessment.
• Graduate of an accredited school of nursing.
• RN - Registered Nurse - Compact State Licensure in good standing.
• Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices.
• Ability to collaborate with cross-operational areas within the organization.
• Good verbal and written communication skills.
• Ability to work as a team member, effectively and collaboratively, with non-clinical teammates.
• Maintain client's privacy, confidentiality and safety as well as act as an advocate for the covered member.
• Adherence to ethical, legal and accreditation/regulatory standards.
• Bachelor’s degree in nursing preferred.
• Intensive care or higher-acuity patient experience preferred.
• Prior experience in utilization management or case management preferred, preferably within the managed care environment.
• Proficiency in maintaining good rapport with other staff members, physicians, health care facilities, clients, and providers.
• Knowledge of managed care in a self-funded employer population is preferred.
• Ability to identify problems such as underutilization or overutilization of services.

Skills

• Ability to promote and maintain quality care through analysis.

Benefits

To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance.
• Income protection benefits: life insurance, short- and long-term disability programs.
• Leave programs to support personal circumstances.
• Retirement Savings Plan includes employer contribution and employer match.
• Paid time off, volunteer time off, and 11 holidays.
• Additional voluntary benefits available and a comprehensive wellness program.

Pay

Details about pay are not specified in this job posting.

Schedule

Details about the schedule are not specified in this job posting.