Contract Utilization Management Nurse

This is a fully remote position, open to applicants in United States.

📋 Description

• Strict compliance with PACE program service authorization policies, ensuring that participant care and associated claims are:

• Appropriate and essential for diagnosis or treatment, aligning with PCP coordination decisions.

• Active engagement in various facets of the utilization management process, including:

• Ongoing review of all hospital admissions (observation and inpatient) with the Interdisciplinary Team to facilitate efficient and timely transitions of care.

• Coordination and assessment of all other services provided by contracted providers, as identified by the PACE program, ensuring alignment with Interdisciplinary Team service authorization, care plans, and PCP coordination decisions.

• Utilize knowledge, critical thinking, and skills effectively to:

• Champion quality care and improve quality of life.

• Keep precise records of all patient-related interactions.

• Conduct a thorough review of provider network appeals.

⛳️ Requirements

• 3 to 5 years of experience in utilization management.

• Current RN license.

• Demonstrated experience in risk-based integrated care models.

• Capability to utilize data for decision-making and collaboration with both internal and external stakeholders.

• Strong strategic thinking, problem-solving, and decision-making abilities.

• Exceptional communication and leadership skills, with the ability to inspire and direct teams towards timely and effective care management strategies.

🏝️ Benefits

• An opportunity to join an innovative team in healthcare technology.

• A collaborative, inclusive, and vibrant work environment.