RN Utilization Review Care Manager

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

📋 Description

• Conduct utilization review care management screenings, assessments, and evaluations.

• Create and execute plans that promote cost-effective and high-quality care.

• Examine and investigate medical records to evaluate benefit utilization and medical necessity.

• Utilize evidence-based guidelines such as InterQual and MCG, along with medical policies for prior authorization and post-service reviews.

• Adhere to NCQA, CMS, state, and plan regulatory guidelines.

• Effectively communicate with members, providers, and both internal and external partners.

• Collaborate with providers to ensure safe and efficient care, appropriate care settings, and smooth transitions of care.

• Work together with physicians, staff, members, and families to expedite authorizations and guide patients to necessary medical care and suitable service settings.

• Address inquiries related to authorizations, treatment plans, and medical necessity determinations.

• Mentor and support UM LPN and non-clinical staff on processes, clinical inquiries, and resource application.

• Provide coverage across Peaks, Canyons, and Desert regions for enterprise-wide shifts.

• Maintain an average work schedule of two days per week, including two weekends within an eight-week timeframe and holiday coverage.

• Work hours from 8:00 AM to 5:00 PM.

⛳️ Requirements

• Valid Registered Nurse (RN) license in the state of practice and compact licensure within the service area.

• Bachelor of Science in Nursing (BSN) from a recognized institution; degree verification is mandatory.

• RNs who are hired or promoted into this position must acquire their BSN within four (4) years from the date of hire or promotion.

• Proven experience in care management/navigation or a closely related field, such as Utilization Management, discharge planning, managed care, health promotion, health coaching, behavioral health, or Patient Educator roles.

• Demonstrated clinical nursing experience in an inpatient hospital environment.

• Familiarity with hospital patient-related terminology and processes.

• Comprehension of disease management, including treatment, length of stay, barriers to care delivery, and variations.

• Excellent written and verbal communication skills, along with strong conflict resolution abilities.

• Basic knowledge of computer hardware setup and the ability to adjust computer settings, utilize multiple monitors, and troubleshoot internet and application issues independently.

• Proficient in Microsoft Office software.

• Capacity to work autonomously, self-motivated, maintain a positive outlook, and adapt to a fast-paced, changing environment.

• Applicants must not live or intend to live in California, Connecticut, Hawaii, Illinois, Massachusetts, Maine, Minnesota, New York, Pennsylvania, Rhode Island, Virginia, Vermont, or Washington.

• Video interview via Microsoft Teams is required.

🏝️ Benefits

• Comprehensive benefits package that includes programs supporting wellness, security, connection, and engagement.

• Options for remote work and company equipment provisions for approved remote positions.