Utilization Management RN

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

📋 Description

• Gather personal and clinical information from participating Plan members.

• Deliver patient education services.

• Make initial assessments of medical appropriateness for communication with the health benefit plan.

• Recognize individuals whose health and/or expenses could benefit from the implementation of Large Case Management.

• Conduct telephonic Clinical Assessments.

• Acquire information from healthcare providers, patients, or families concerning planned procedures, admissions, ongoing stays, or discharge plans.

• Analyze nationally recognized criteria to back recommendations for inpatient and outpatient services.

• Identify and refer individuals for Case Management services.

• Thoroughly document each call in the computer system, ensuring accuracy and timeliness.

• Adhere to policies and procedures regarding confidential materials and patient-specific information.

• Respond to direct phone calls to ascertain if prior authorization is necessary.

• Retrieve and respond to voicemail messages requesting medical services.

• Complete medical necessity reviews and communicate results to providers within designated time frames.

• Supply educational materials and direct callers to community services when appropriate.

• Support professional colleagues by providing coverage as needed.

⛳️ Requirements

• Valid and unrestricted RN License.

• Minimum internet speeds of 25Mbps download and 25 Mbps upload.

• At least 1 year of experience in a hospital environment.

• Excellent verbal communication abilities.

• Strong problem-solving and decision-making capabilities.

• Competence in following detailed written or verbal instructions independently.

• Proficient in Microsoft Office Suite (Outlook, Word).

• Preferred: Over 1 year of prior UM experience.

• Preferred: Familiarity with Interqual criteria.

🏝️ Benefits

• Enjoy the flexibility of working from home.

• Monday to Friday work schedule.

• 40-hour work week.