Utilization Management Nurse

Medical Associates • Dubuque, IA

215d • Remote

About The Position

Medical Associates is looking for a Utilization Management Nurse to join our Health Care Services team! The primary schedule will be Monday through Friday from 8:00am to 5:00pm, totaling 40 hours per week with flexibility. After training, there is an opportunity for work from home if desired! The training will be conducted in-person at Medical Associates Health Plans, located at 1605 Associates Drive, Dubuque, IA 52002.

Requirements

• Three to five years of similar or related experience.
• Valid RN nursing license is required.

Responsibilities

• Review requests from providers or members for approval of procedures, medications, durable medical and/or services prior to delivery of the service.
• Utilize established screening criteria to ensure patients get the correct treatment from the resources that are available at the most cost effective level to meet their needs.
• Facilitate options and services for meeting individuals' health needs with the goal of decreasing fragmentation, duplication of care and enhancing quality, cost‑effective clinical outcomes.
• Review hospital and skilled admissions to justify continued care as medically necessary per Health Plan established guidelines.
• Conduct reviews inclusive of physician referrals, medication reviews, admissions, utilization review updates, and investigating alternatives to hospitalization such as home health care and durable medical equipment.
• Utilize the assessment process by obtaining pertinent patient history and accurate vital data, anticipating patient and family needs.
• Work with the Health Choice Claims and Membership Services to determine benefit eligibility, facilitate crisis intervention, and share information with co‑workers while documenting accurately.
• Utilize established screening criteria to determine medical necessity of requested authorizations.
• Refer patients to case management nurse or health coach as appropriate.
• Facilitate out‑of‑plan referrals, out‑of‑area urgent and emergent care for enrollees and provider offices, providing necessary information to the Medical Director on specified referrals.
• Communicate decisions to enrollees, providers, and facilities per established policies.
• Work collaboratively with internal and external staff in determining the extent of benefits and coverage for services being coordinated.
• Document authorizations, denials, cost savings, and other outcome measurements.
• Act as a resource for the enrollee, provider offices, and other MAHP departments.
• Perform retrospective review to determine coverage of hospitalizations and outpatient services.
• Communicate with enrollees regarding the use of managed care systems and participate in answering inquiries from enrollees and providers.
• Assist in preparations for external review/regulatory agencies.
• Complete all other assigned projects and duties.

Benefits

• Single or Family Health Insurance with discounted premium rates for wellness program participation.
• 401k with immediate matching (50% on the dollar up to 7% of pay + additional annual Profit Sharing).
• Flexible Paid Time Off Program (24 days off/year).
• Medical and Dependent Care Flex Spending Accounts.
• Life insurance, Long Term Disability Coverage, Short Term Disability Coverage, Dental Insurance, etc.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree