Utilization Management Nurse - JHP

Jefferson Health Plans • Philadelphia, PA

22h • Onsite

About The Position

The Utilization Management Nurse is responsible for ensuring cost-effective, quality utilization management in acute and post-acute inpatient settings, serving pediatric or adult populations. The role reviews clinical information provided by facilities and communicates utilization management determinations within required timeframes. The position is based at 1101 Market in Philadelphia, Pennsylvania, and includes after-hours on-call coverage as needed.

Requirements

• Active Registered Nurse license to practice professional nursing in the Commonwealth of Pennsylvania.
• Two years of medical/surgical, utilization review, and emergency room experience.
• Thorough understanding of managed care systems and utilization review criteria.
• Recent experience in a hospital, insurance company, or independent review company in utilization, quality review, or case management.
• Knowledge of health insurance, including Medicare, Medicaid, and managed care.
• Ability to work and communicate effectively with coworkers, members, and providers at the owner institutions.
• Organized, detail-oriented, and capable of handling multiple issues.
• Excellent telephone, verbal, and written communication skills.
• Proficiency with Microsoft Office, including Word, PowerPoint, and Excel.
• Ability to present a polished, professional image.

Nice To Haves

• Bachelor of Science in Nursing (BSN) preferred.

Responsibilities

• Review and track emergency admissions to identify the appropriate level of care for acute and post-acute inpatient services.
• Perform concurrent and/or admission reviews of hospital admissions using InterQual criteria guidelines.
• Track assigned cases to ensure timely reviews, updates, and decisions are reflected in case documentation.
• Request and review medical records to identify appropriate acute care days, approving them or referring questionable days to the medical director for a decision.
• Act as a liaison among providers, members, and internal departments.
• Serve as a resource for physicians, primary care providers, Utilization Review departments, and other medical providers.
• Identify utilization trends 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.
• Provide after-hours on-call coverage and work on-call shifts as needed.
• Participate in relevant work groups and provide deliverables as necessary.
• Complete assignments accurately and on time in accordance with departmental and company operational objectives, and seek feedback on performance.
• Schedule and complete assignments accurately and promptly; maintain detailed knowledge of assignment status and routinely update the manager as appropriate.
• Perform other duties as assigned.

Benefits

• Medical insurance, including prescription coverage
• Supplemental insurance
• Dental insurance
• Vision insurance
• Life and AD&D insurance
• Short- and long-term disability
• Flexible spending accounts
• Retirement plans
• Tuition assistance
• Voluntary benefits, including access to group insurance rates and discounts
• Tuition discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service
• Medical insurance, including prescription coverage, is available to all colleagues, including those working less than part-time

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed