Job Summary:

The Utilization Management (UM) Nurse will work, learn, and develop knowledge and skills in utilization management, medical necessity, and care coordination. This individual is responsible for performing a variety of prospective, concurrent, and retrospective UM-related activities. The UM nurse’s role is to ensure that healthcare services are administered with quality, cost efficiency, and within compliance and regulation standards. The UM Nurse is also responsible for participating in initial clinical review.

Job Responsibilities

· Performs prospective, concurrent, and retrospective medical necessity reviews for healthcare products and services utilizing appropriate clinical criteria and/or evidence-based guidelines.

· Performs level of care (LOC) determinations and monitors length of stay based on severity of illness and intensity of service using the appropriate clinical criteria.

· Conducts initial clinical review (in accordance with accreditation, laws, and regulations).

· Ensures regulatory and/or accreditation guidelines are met for timeliness of medical necessity reviews.

· Verifies accuracy of codes and services and applies them accurately with appropriate documentation.

· Coordinates discharge planning needs and transition of care with the registered nurse case managers and other healthcare team members, as deemed appropriate.

· Communicates member, provider, and facility notifications, citing clinical criteria and Medical Director denial rationale, when indicated.

· Collaborates with a multi-disciplinary staff and interdepartmentally.

· Establishes and maintains professional relationships with providers and facilities to establish a smooth operational flow of authorizations and referrals.

· Evaluates, coordinates, manages, and documents all UM-related activities.

· Maintains a current knowledge of medical necessity criteria and UM-related policies and procedures.

· Assists in the development and maintenance of medical necessity criteria and clinical pathways.

· Participates in the monitoring of the effectiveness and outcomes of the UM program.

· Participates in UM program process improvement initiatives.

· Complies with all regulatory and accreditation standards related to utilization management and/or case management.

· Complies with Utilization Management and Case Management standards of practice.

· Performs other duties as assigned.

Qualifications:

1. Education and/or Training:

· Associate’s degree in nursing required.

· Bachelor’s degree in nursing preferred.

2. Professional Experience:

· 0 – 2 years of experience in utilization management or case management is preferred.

· Knowledge of Medicare is preferred.

· Knowledge of Medicaid, HMO, and private insurance is preferred.

3. Licenses/Certifications:

· Current active, unrestricted state licensure as a Registered Nurse is required.

· Utilization Management or Case Management certification is preferred.

4. Specialized Skills:

· Professional license must be with a scope of practice that will be relevant to initial clinical review.

· Clinical background and judgement to conduct initial clinical review is required.

Job Types: Full-time, Part-time

Expected hours: 15 – 20 per week

Schedule:

Choose your own hours
Monday to Friday

Experience:

Utilization review: 1 year (Preferred)

License/Certification:

RN (Preferred)

Work Location: Remote

RxAdvance/ NirvanaHealth

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