About This Position
Position Summary
As a Utilization Management Nurse you will work with members to ensure they obtain the proper healthcare in the most cost-effective manner. The Utilization Management Nurse will also review planned, in-process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria.
Key Responsibilities (included but not limited to): · Conduct thorough reviews of medical records, treatment plans, and other relevant documentation to determine the medical necessity and appropriateness of healthcare services.· Communicate with healthcare providers, insurance companies, and other stakeholders to gather necessary information and discuss patient care plans.· Maintain detailed records of utilization management activities, including findings, decisions, and communications with stakeholders.· Ensure that all utilization management activities adhere to regulatory requirements, accreditation standards, and organizational policies and procedures.· Identify opportunities to optimize healthcare resources, such as by recommending alternative treatments or care settings that may be more cost-effective or clinically appropriate.· Advocate for patients' rights and ensure that they receive timely and appropriate healthcare services based on their individual needs.· Participate in quality improvement initiatives aimed at enhancing the efficiency, effectiveness, and safety of healthcare delivery.· Coordinate peer-to-peer reviews between providers and medical directors in determining coverage of requested services.· Refer members with costly medications or non-covered medications to ScriptAide for assistance via the Patient Assistance Program or the Prescription Importation Program.· Collaborate with the Medical Director on review of procedures/medications that do not meet medical necessity review per clinical guidelines. · Provide procedure and/or medication cost to the member’s plan.
Career experience required:
· Active RN license preferred; or, LPN license
· Health plan utilization management experience
· Strong clinical assessment skills
· Excellent communication and interpersonal skills
· Ability to work independently and collaboratively in a fast-paced environment
· Knowledge of healthcare regulations and reimbursement policies
· Experience with a TPA or in the health insurance industry preferred
Behavioral competencies desired:
· Critical Thinking – Use of exceptional critical thinking skills and attention to detail
· Analytical Skills – Analyze information and exercise sound judgement when making decisions
· Innovation – Take a multi-faceted approach to problem-solving and creation of novel solutions to problems. Champion organization-wide learning and sharing of information. Take a viewpoint that is broader than one’s immediate group or department and encompasses external factors.
· Collaboration – Understand the importance of relationships to enable effective teamwork. Modify personal style, focus on the needs of others, and listen effectively to ensure effective outcomes for group endeavors.
· Business Acumen – Knowledge of general business practices in the TPA world as well as knowledge of the organization’s functioning. An understanding of organizational culture and the ability to function effectively within its social structure.
Pay: $75,000.00 - $85,000.00 per year
Work Location: In person
As a Utilization Management Nurse you will work with members to ensure they obtain the proper healthcare in the most cost-effective manner. The Utilization Management Nurse will also review planned, in-process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria.
Key Responsibilities (included but not limited to): · Conduct thorough reviews of medical records, treatment plans, and other relevant documentation to determine the medical necessity and appropriateness of healthcare services.· Communicate with healthcare providers, insurance companies, and other stakeholders to gather necessary information and discuss patient care plans.· Maintain detailed records of utilization management activities, including findings, decisions, and communications with stakeholders.· Ensure that all utilization management activities adhere to regulatory requirements, accreditation standards, and organizational policies and procedures.· Identify opportunities to optimize healthcare resources, such as by recommending alternative treatments or care settings that may be more cost-effective or clinically appropriate.· Advocate for patients' rights and ensure that they receive timely and appropriate healthcare services based on their individual needs.· Participate in quality improvement initiatives aimed at enhancing the efficiency, effectiveness, and safety of healthcare delivery.· Coordinate peer-to-peer reviews between providers and medical directors in determining coverage of requested services.· Refer members with costly medications or non-covered medications to ScriptAide for assistance via the Patient Assistance Program or the Prescription Importation Program.· Collaborate with the Medical Director on review of procedures/medications that do not meet medical necessity review per clinical guidelines. · Provide procedure and/or medication cost to the member’s plan.
Career experience required:
· Active RN license preferred; or, LPN license
· Health plan utilization management experience
· Strong clinical assessment skills
· Excellent communication and interpersonal skills
· Ability to work independently and collaboratively in a fast-paced environment
· Knowledge of healthcare regulations and reimbursement policies
· Experience with a TPA or in the health insurance industry preferred
Behavioral competencies desired:
· Critical Thinking – Use of exceptional critical thinking skills and attention to detail
· Analytical Skills – Analyze information and exercise sound judgement when making decisions
· Innovation – Take a multi-faceted approach to problem-solving and creation of novel solutions to problems. Champion organization-wide learning and sharing of information. Take a viewpoint that is broader than one’s immediate group or department and encompasses external factors.
· Collaboration – Understand the importance of relationships to enable effective teamwork. Modify personal style, focus on the needs of others, and listen effectively to ensure effective outcomes for group endeavors.
· Business Acumen – Knowledge of general business practices in the TPA world as well as knowledge of the organization’s functioning. An understanding of organizational culture and the ability to function effectively within its social structure.
Pay: $75,000.00 - $85,000.00 per year
Work Location: In person
