CM Utilization Management Nurse

Group Health Cooperative of South Central Wisconsin•Madison, WI

3d•Remote

About The Position

Using a collaborative process, the Care Management (CM) Utilization Management Nurse (RN) will review, plan, implement, monitor, and evaluate the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, and cost-effective outcomes. They help identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner while maintaining quality of care. The CM Utilization Management Nurse is responsible for evaluating the medical appropriateness, quality, and cost effectiveness of proposed services in accordance with established criteria. This review activity may be conducted prospectively, concurrently, or retrospectively and in collaboration with patients, practitioners, and other professionals. They play an integral role in working with the RN and Social Work Case Managers on an ongoing basis and providing support. They provide support and is a resource for the Care Management Associates and other staff. Work is performed under the general direction, guidance, and supervision of the Care Management Department Manager. GHC-SCW is a quality driven cooperative built on collaboration, community involvement, innovation, and belonging. In dedication to the health and well-being of our employees, we offer a comprehensive benefits package that includes health and dental insurance, along with paid parental leave, short-term disability, long-term disability, and life insurance. Additional benefits include a flexible spending account, employee assistance programs, tuition reimbursement, pet insurance, eyewear discounts, and more. Check us out by clicking on Many Talents, One Mission! The Benefits of Working at GHC-SCW.

Requirements

Graduation from an NLN accredited school of Nursing.
Valid current license to practice in the State of Wisconsin as a Registered Nurse is required.
Minimum of one (1) year experience in: Utilization Review, Insurance/Managed Care, Home Health and/or diversified clinical experience, two (2) years preferred.
Knowledge of utilization principles, methods, and techniques with experience in primary and/or acute care management.
Ability to follow established criteria, policies, and procedures utilized in medical reviews.
Ability to keep abreast of legal and regulatory changes affecting the delivery of care.
Excellent oral and written communication skills required.
Ability to communicate effectively in person, in groups, and on the telephone.
Ability to be culturally sensitive and to work with a diverse patient population.
Knowledge of and ability to use computer-based applications such as MS Office, (word processing, email, calendar).
Knowledge of and/or ability to learn and effectively use electronic medical and insurance record systems.
Ability to maintain patient and organizational confidentiality required.
Knowledge of or ability to learn HIPAA requirements.
Knowledge of medical records and appropriate documentation requirements.
Ability to apply clinical criteria to analyze requests.
Self-motivation and self-direction required; capable of working independently with limited direct supervision.
Excellent customer service skills.
Ability to work effectively with all levels of staff, practitioners, internal departments, external parties and members.
Strong organizational skills.
Ability to pay attention to details.
Ability to function as a team player.
Possession of a valid Wisconsin Driver License with good driving record.
Employee must be able to provide own transportation to various worksites.
Ability to sit, stand, walk, and drive on a regular basis required.
The incumbent knows and abides by all Group Health Cooperative of South Central Wisconsin (GHC-SCW) organizational and departmental policies, sets personal standards and strives for high quality work in completing assignments, performs job duties in a timely manner, and represents the organization in a positive manner.
The incumbent understands our Mission, Vision, and Common Values (stated below) and is committed to promote these values in behavior and attitude.

Nice To Haves

Bachelor’s degree is preferred.
Two (2) years preferred experience.
Experience with EPIC systems is desirable but not required.

Responsibilities

Review, plan, implement, monitor, and evaluate the options and services required to meet an individual’s health needs
Identify appropriate providers and facilities throughout the continuum of services
Evaluate the medical appropriateness, quality, and cost effectiveness of proposed services in accordance with established criteria
Provide support and is a resource for the Care Management Associates and other staff