Utilization Management nurse
About The Position
The Medical/Utilization Management nurse helps improve patient health and satisfaction and ensures members receive appropriate medical care. This part-time role works 10–20 hours per week and is part of the Medical Management Team, collaborating with the UM Medical Director, UM Department Manager, and Customer Service. The nurse coordinates IPA member care through knowledgeable, clear, timely, effective, and compassionate communication. The role includes reviewing member authorizations for clinical appropriateness and medical necessity using supporting medical documentation and evidence-based clinical guidelines. It also involves case management and care coordination, supporting members who may benefit from those services, coordinating care with the Priority Care Center and local providers, and facilitating follow-up care after hospitalization. The nurse also coordinates behavioral health and legal assistance referrals for Employee Assistance Program members, participates in quality and medical management meetings, contributes feedback on processes and policies, participates in health plan audits and quality improvement projects, and performs other duties as assigned.
Requirements
- Current Registered Nursing License.
- Computer proficiency and ability to navigate multiple programs, electronic medical records, and web-based meetings.
- Responsible, organized, and detail-oriented.
- Excellent time-management skills and ability to shift priorities.
- Ability to document clearly and succinctly.
- Understanding of healthcare administration and related regulations.
- Excellent communication skills.
- Ability to coordinate and collaborate with patients, providers, and IPA staff.
- Proactive, problem-solving approach.
- Ability to adapt to change in the IPA and the broader healthcare environment.
- Positive attitude and professional demeanor.
- Self-motivated and follows through on assignments.
- Ability to work autonomously.
- Mindful of coworkers and patients; caring, curious, and kind demeanor.
Nice To Haves
- Nursing experience in Case Management and patient care.
Responsibilities
- Review IPA member authorizations for clinical appropriateness and medical necessity by assessing supporting medical documentation and using evidence-based guidelines.
- Work with the Priority Care Center Team to identify members who may benefit from Intensive Care Coordination.
- Participate in weekly multidisciplinary Care Coordination meetings and help develop multidisciplinary Care Plans to optimize member health, patient care, and appropriate healthcare delivery.
- Help identify members who may benefit from Case Management or Care Coordination.
- Inform members about IPA and Priority Care Center services, including primary care access and same-day appointments, behavioral health providers, Shared Decision Making, Intensive Care Coordination, and Wellness Coaching.
- Follow hospitalized IPA members, communicate with hospital staff about discharge planning, identify care coordination needs, and facilitate timely follow-up care.
- Accept calls from Employee Assistance Program members and coordinate behavioral health and legal assistance referrals in the local community.
- Participate in monthly Quality Medical Management meetings to discuss complicated cases referred to a local committee of physicians.
- Participate in monthly Medical Management Committee meetings to discuss patients receiving or needing Care Coordination, hospitalized members, and other agenda items.
- Provide feedback and insight on improving processes and policies.
- Participate in health plan audits and quality improvement projects.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Part-time
Education Level
Associate degree
