Utilization Management & Case Manager, Registered Nurse (FT, Remote)

Our team works diligently to ensure that beneficiaries progress toward desired outcomes with quality care that is medically appropriate and cost-effective. Our goal is to assist beneficiaries in regaining their optimal health or improved functional capability, support effective self-care management, and promote access to healthcare services and community resources.

• Review authorization requests using clinical judgment and evidenced-based clinical decision support criteria to ensure medical necessity and appropriate level of care. 
• Assesses services for beneficiaries to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. 
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures. 
• Conducts authorization reviews to determine financial responsibility for the payer and its beneficiaries. 
• Approve services or refer cases to internal stakeholders based on findings. 
• Makes appropriate referrals to other clinical programs. 
• Refers appropriate authorization requests to and collaborates with Medical Directors. 
• Educate providers on utilization and medical management processes. 
• Enter and maintain clinical information in various medical management systems. 
• Make evidenced-based independent decisions regarding work methods, even in ambiguous situations, with minimal direction. 
• Analyzes clinical service requests from beneficiaries or providers against evidence based clinical guidelines. 
• Processes requests within required timelines. 
• Collaborates with multidisciplinary teams to promote the care model. 
• Adheres to all UM policies and procedures, federal, state and regulatory guidelines.
• Conduct a comprehensive assessment with beneficiaries and analyze assessment findings to identify and prioritize clinical, psychosocial, and behavioral concerns and potential gaps in care. 
• Develop and document a case management care plan in direct collaboration with the beneficiary, the beneficiary's family or significant other(s), the primary physician and other health care providers. Identify and include key concerns, needs, and preferences of the beneficiary and family/caregiver.  
• Document identified issues, prioritized and individualized goals (long & short term), evidence-based interventions, collaborative approaches and resources, anticipated time frames, and barriers to achieving goals in the care plan.
• Coordinate and implement the activities specified in the care plan to provide optimal benefits coverage as well as promote continuity of care and integration of services for the beneficiary across care transitions.  Collaborate and communicate with the beneficiary, family, significant other(s), physician, and other health care providers to accomplish the goals on the care plan.
• Monitor and continually evaluate the care plan on a scheduled basis to ensure it remains effective and to determine if desired outcomes are met and the goals are achieved.  Revise and update the care plan as needed in collaboration with the beneficiary and the health care team.
• Collaborate with beneficiaries and their support system/caregivers, providers, the multi-disciplinary team, and health care and community resources throughout the case management process.
• Be familiar with and understand the scope of professional licensure and carry out case management activities consistent with the scope of this licensure.  

Work schedule Monday - Friday 5 days x 8 hours  

Shift time for remote telephonic work is aligned to state of residence and time zone:   

Pacific Time Zone          9 am - 6 pm PT  

Mountain Time Zone     10 am - 7 pm MT  

Central Time Zone         11 am - 8 pm CT  

Eastern Time Zone        11 am - 8 pm ET  

Required 

• Must hold United States Citizenship status 
• Current, unrestricted Registered Nurse (RN) license in state of residence with multi-state privileges (an active compact state license)
• 3+ years of experience as a nurse in a clinical setting 
• 2+ years’ experience performing the utilization review for a health plan or inpatient facility
• 1+ year of experience as a case manager for a health plan or inpatient facility
• Strong technical proficiency with MS Office Suite Word, Excel, Power Point, Microsoft Teams and SharePoint and ability to navigate multiple systems under periods of high volume. 
• Ability to obtain Security Clearance required. Current DOD Security Clearance preferred.
• Secure, private home office work environment 

Preferred 

• Bachelor’s degree in nursing from an accredited college, university, or school of nursing 
• Previous experience in Hospital Acute Care, Prior Auth, Utilization Review / Utilization Management and knowledge of InterQual and/or MCG guidelines 
• Health Plan experience working with large carriers. Previous Federal government plan program experience such as Tricare, Medicare Medicaid and commercial health insurance experience 
• Active, Utilization Management Certification (CPHM) 
• Active, Certified Case Management Certification (CCM)
• Experience working remotely

Join us! Use your skills to make a meaningful impact on the lives of patients. We offer a supportive environment where you can thrive and grow professionally while helping others achieve better health outcomes.

What We Offer:

• EXL Health offers an exciting, fast paced, and innovative environment, which brings together a group of sharp and entrepreneurial professionals who are eager to influence business decisions.
• From your very first day, you get an opportunity to work closely with highly experienced, world class Healthcare consultants.
• You can expect to learn many aspects of businesses that our clients engage in. You will also learn effective teamwork and time-management skills - key aspects for personal and professional growth.
• We provide guidance/ coaching to every employee through our mentoring program wherein every junior level employee is assigned a senior level professional as advisors.
• Sky is the limit for our team members. The unique experiences gathered at EXL Health sets the stage for further growth and development in our company and beyond.