Utilization Management Nurse

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

📋 Description

• Assess and oversee members' use of healthcare services to ensure high-quality, cost-efficient care.

• Analyze the suitability and effectiveness of medical services and procedures.

• Facilitate prior authorizations, conduct concurrent reviews, initiate proactive discharge/transition planning, and review high-cost claims.

• Carry out both concurrent and retrospective evaluations on facility and suitable home health services.

• Supervise the level and quality of care while proactively managing patients with acute and chronic conditions.

• Assess and provide insights regarding discharge plans, covered services, and alternative care levels.

• Determine observational versus acute inpatient status during hospital prior authorization procedures.

• Collaborate with providers to engage in proactive discharge and transition planning.

• Prepare CMS-compliant notification letters and review non-certification documentation.

• Keep accurate records of communications and monitor utilization reports for compliance and turnaround times.

• Coordinate interdisciplinary care to ensure continuity of care.

• Issue appropriate authorizations for covered services.

• Identify and report potential high-cost/utilization cases for reserve allocation.

• Suggest cost-saving measures and improvements in quality of care.

• Clarify health plan benefits, policies, and procedures for both members and providers.

• Identify members who may qualify for the Chronic Care Improvement Program.

• Identify and report potential quality-of-care issues.

• Function as a member of an interdisciplinary team within Medical Management and across various departments.

⛳️ Requirements

• A minimum of 2 years of clinical experience as an RN or LPN/LVN is required.

• At least 1 year of experience in managed care or a similar health plan is preferred.

• Proven experience in health plan utilization management, facility concurrent review, discharge planning, and transfer coordination is required.

• Medicare Advantage experience is preferred.

• Familiarity with InterQual or MCG authorization criteria is preferred.

• Excellent computer skills and the ability to quickly learn new systems are required.

• Strong attention to detail, organizational abilities, and interpersonal skills are essential.

• Demonstrated problem-solving skills and the ability to manage professional relationships are required.

• An active, unrestricted nursing license is required.

• The company is currently unable to provide visa sponsorship (H1B or otherwise).

🏝️ Benefits

• Primarily a remote telephonic position.

• Standard business day hours.

• Coverage required for one weekend day each month.

• Opportunity to contribute to enhancing the health, happiness, and dignity of older adults.

• Commitment to Equal Employment Opportunity.