Registered Nurse Utilization Management Reviewer

Intermountain Health

1d • Hybrid

About The Position

The RN Utilization Management Reviewer I utilizes clinical expertise and critical thinking skills to conduct utilization review care management screenings, assessments, and evaluations while prioritizing stewardship of resources. This role is responsible for developing and implementing a plan that supports cost effective, extraordinary care. This position works collaboratively with patients, patient families/significant others, healthcare providers, insurers, and other involved parties to ensure compliant, efficient, effective, and patient-centered utilization review services. This is a full-time hybrid position, primarily remote, with required onsite availability for 1:1's, meetings, trainings, etc. as needed, with the Nevada Central Office in Las Vegas serving as the home base. The ideal candidate will possess critical thinking skills and attention to detail, with utilization management experience preferred.

Requirements

• Current Registered Nurse (RN) license in state of practice, and compact licensure within service area states.
• Bachelor of Science in Nursing (BSN) from an accredited institution (degree verification required.) RNs hired or promoted into this role must obtain their BSN within four (4) years of hire or promotion.
• Demonstrated experience in care management/navigation or closely related field including utilization management, discharge planning, managed care, health promotion, health coaching, behavioral health, or patient educator role.
• Demonstrated clinical nursing experience in an inpatient hospital setting, and familiarity with hospital patient-related terminology and processes.
• Demonstrated understanding of disease management including treatment, length of stay, identifying barriers to delivery of care and any variation.
• Demonstrated excellent written and verbal communication skills.
• Ability to work independently and be flexible in a rapidly changing environment.
• Proficiency with basic computer hardware set-up, ability to customize computer settings and use multiple monitors, and capable of independently troubleshooting internet and applications.

Nice To Haves

• One (1) year experience in care management/navigation or closely related field including utilization management, discharge planning, managed care, health promotion, health coaching, behavioral health, or patient educator role.
• Three (3) years of experience and expertise working in clinical nursing in an ambulatory care setting, community health or home care.
• Bachelor of Science in Nursing (BSN) from an accredited institution.
• Case Management, Utilization Management, or Health Care Quality Certification.
• Experience working with third party payers.
• Experience working successfully working in a remote environment or using Advanced Microsoft Suite, including Teams (chat, whiteboard, task tracking) & Outlook.

Responsibilities

• Reviews and investigates medical record and applies clinical expertise to assure appropriate benefit utilization, and medical necessity as relates to requested services, authorization history, and treatment plan.
• Uses in-depth knowledge of medical procedures, treatments, and diagnosis to apply evidence-based guidelines (e.g. InterQual/MCG) and medical policies for prior authorization and post service reviews.
• Follows the applicable regulatory guidelines (NCQA, CMS, State) and ensures timely review with clear accurate communication to members and requesting providers.
• Based on medical necessity and clinical best practice proactively engages with providers to ensure safe and efficient medical care, appropriate care setting, and safe transitions of care referring to alternate programs as applicable.
• Collaborates with physicians, internal staff, members, and families to assist in expediting the requested authorizations, and directs toward medically necessary care and the correct level/setting for services requested.
• Adheres to regulatory guidelines and timely communication with members, providers, and internal/external partners.
• Engages proactively with members and providers for safe, efficient care and transitions as applicable to continuity of care, redirection, and authorization determination.
• Resolves queries regarding authorizations, treatment plans, and medical necessity determinations.
• Mentors and guides the UM LPN on clinical questions and application of resources.

Benefits

• Generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.
• PEAK program: up-front tuition coverage paid directly to the academic institution.
• PEAK program: 100+ learning options including undergraduate studies, high school diplomas, and professional skills and certificates.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees