RN Coordinator Utilization Management

Network Health WI•Menasha, WI

2d•Hybrid

About The Position

The RN Coordinator Utilization Management reviews submitted authorization requests for medical necessity, appropriateness of care, and benefit eligibility. This position reviews applicable guidelines regarding payment and coverage, and makes determinations for authorization/payment. Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required). Travel to the corporate office in Menasha is required occasionally for the position, including on the first day. Training is required in person at our Menasha location for the first 6-8 weeks.

Requirements

Associate Degree in Nursing, required
Current registered nurse licensure in Wisconsin required
Minimum of four (4) years clinical health care experience as a Registered Nurse (RN) required

Nice To Haves

Bachelor of Science in Nursing, preferred
Experience in insurance, managed care and utilization management preferred

Responsibilities

Evaluate and process prior authorization requests/referrals submitted from contracted and non-contracted providers
Follow Network Health process, policies, and procedures in authorization review of all membership on a pre-service, concurrent and post-service basis. This process includes verifying eligibility and benefits, as well as documenting all utilization management communication
Provide education regarding utilization management activities and processes to members, caregivers, providers, and their administrative staff
Participate in Utilization Management auditing (i.e. Utilization Management Inter-reviewer reliability and denial files)
Refer all members with complex health problems and needs to Network Health Case Management to reduce medical costs while providing a higher quality of life and an ability to take charge of their diseases. This requires an extensive holistic approach to care management assessment
Collaborate with other NH departments to develop interdepartmental operational processes
Support Utilization Management department programs and goals through active participation
Identify and screen candidates for Case Management intervention and determines appropriate level of care from Utilization Management criteria
Complete assessments and plans of care including need for medication regime, treatment plans, practitioner follow-up appointments, knowledge of red flags, disease management, Advance Directives, life planning, and self-management of illness to the best of member ability
Evaluate cases for cost savings/quality improvement potential
Other duties and responsibilities as assigned