Utilization Management Nurse (RN) - Jefferson Health Plan

Jefferson Health Plans • Philadelphia, PA

2d

About The Position

The Utilization Management Nurse is responsible assure cost effective, quality utilization management in the acute level of care setting for the pediatric or adult population in the post-acute inpatient setting (i.e.,SNF/Rehab). Also, responsible to review clinical information provided by facilities and communicates UM determinations maintaining timeliness. Job Description Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson. Review and track emergency admissions to identify appropriate level of care for acute and post-acute inpatient services. Perform concurrent review and/or admission review on all hospital admissions using InterQual criteria guidelines. Track assigned cases for timely reviews/updates and decisions as reflected in case documentation. Request and review medical records to identify appropriate acute care days and approve or refer questionable days to the medical director for decision. Function as a liaison between providers, members and interdepartmentally. Serve as resource for physicians, PCPs, Utilization Review departments and all medical providers. Identify trends that impact on utilization at hospitals during the review process and help resolve them. Maintain departmental and regulatory timeframes for utilization decisions. Contributes to the development and enhancement of documentation, tracking tools and process flows Maintains collaborative and effective cross- functional training within the Utilization Management Department Utilization management perform after hour’s on-call coverage. Participates in relevant work groups and provide deliverables as necessary Successful and timely completion of assignments in accordance with departmental and Company operational objectives and seeks feedback on performance. Ensures that assignments are scheduled and completed in an accurate and timely manner. Maintains detailed knowledge of the status of all assignments and routinely updates the manager, as appropriate Responsible to for after hour on call shifts as needed Performs all other duties as assigned

Requirements

• Graduate of an accredited nursing program (Associate’s or Bachelor’s degree in Nursing)
• Minimum of 2-3 years of clinical nursing experience

Nice To Haves

• BSN preferred
• At least 1 year of utilization management, case management, or managed care experience preferred

Responsibilities

• Assure cost effective, quality utilization management in the acute level of care setting for the pediatric or adult population in the post-acute inpatient setting (i.e.,SNF/Rehab)
• Review clinical information provided by facilities and communicates UM determinations maintaining timeliness
• Interact with co-workers, visitors, and other staff consistent with the values of Jefferson
• Review and track emergency admissions to identify appropriate level of care for acute and post-acute inpatient services
• Perform concurrent review and/or admission review on all hospital admissions using InterQual criteria guidelines
• Track assigned cases for timely reviews/updates and decisions as reflected in case documentation
• Request and review medical records to identify appropriate acute care days and approve or refer questionable days to the medical director for decision
• Function as a liaison between providers, members and interdepartmentally
• Serve as resource for physicians, PCPs, Utilization Review departments and all medical providers
• Identify trends that impact on utilization at hospitals during the review process and help resolve them
• Maintain departmental and regulatory timeframes for utilization decisions
• Contribute to the development and enhancement of documentation, tracking tools and process flows
• Maintain collaborative and effective cross- functional training within the Utilization Management Department
• Perform after hour’s on-call coverage
• Participate in relevant work groups and provide deliverables as necessary
• Complete assignments in accordance with departmental and Company operational objectives and seeks feedback on performance
• Ensure that assignments are scheduled and completed in an accurate and timely manner
• Maintain detailed knowledge of the status of all assignments and routinely updates the manager, as appropriate
• Responsible to for after hour on call shifts as needed
• Perform all other duties as assigned

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 501-1,000 employees