Utilization Management Nurse

Job Role

Clinical care (UM) nurses coordinate overall member care, from pre-admission, continued stay (concurrent review) and any outpatient services utilizing a pro-active, evidence-based decision-making process that is physician sensitive and attaining quality outcomes for the members. The clinical care nurse serves as a nurse reviewer for admissions, lengths of stay and a facilitator for discharge planning. This position functions as a liaison between the providers, hospitals and health plans. Responsible for the implementation of client-specific contracted polices, managed care policies and must be very knowledgeable about benefits, criteria and guidelines used for reviews. Must be adept at identifying and referring potential quality of care issues to the Medical Director, client and/or appropriate staff.

Responsibilities:

• Initiating the continuum of care process for neonatal admissions.
• Interacting telephonically and in writing with hospital staff to collect clinical information for newborns in intensive care nurseries in order to facilitate medical necessity determinations.
• Coordinating discharge planning needs for newborns being discharged from intensive care nurseries.
• Authorization of all services requiring prior authorization, based upon health plan specific service agreements.
• Review of all services (readmissions and elective procedures) for first year of life.
• Documenting all activities in the electronic medical record.
• May include evening and/or weekend on call.

Qualifications

• Registered Nurse (RN) with a current, unrestricted license is required
• Three or more years of clinical experience as a nurse in a Level III or Level IV NICU is required.
• Three or more years of experience working in a concurrent review or discharge planning role within a health plan or an acute facility is strongly preferred.
• Must be willing to provide weekend and holiday coverage occasionally.
• Experience with Interqual and/or MCG is preferred.
• Experience with URAC and/or NCQA standards is preferred.
• Experience with data entry into a database or EHR required. Must have strong computer skills.
• Must be self-motivated and willing to learn multiple tasks. Must be well organized and able to prioritize tasks.
• Must demonstrate accuracy in spelling and documentation.
• Ability to perform job functions with autonomy and be a self-starter.
• Must possess excellent interpersonal skills, telephone etiquette and maintain positive communication at all times.
• Must have commitment to excellence in customer service.

Benefits

Some of the benefits we offer our team are:

• Paid Time Off
• Paid Parental Leave
• Medical, dental, vision benefits
• 401K with company match
• Short- and Long-Term Disability
• Group Life Insurance
• Tuition reimbursement
• Professional development opportunities
• Business Casual work environment