Utilization Management Nurse

IntusCare

21h•$75,000 - $90,000•Remote

About The Position

The Utilization Management Nurse plays a critical role in ensuring high-quality, cost-effective, and compliant care for PACE participants supported by IntusCare. This individual partners closely with PACE Interdisciplinary Teams, Medical Directors, and provider networks to review service utilization, guide care decisions and support timely, appropriate transitions across care settings. Blending clinical expertise with analytical thinking, the Utilization Management Nurse ensures services are medically necessary, aligned with care plans and consistent with PACE regulations and best practices. This role is essential to maintaining program integrity, improving participant outcomes and supporting the delivery of coordinated, value-based care.

Requirements

3 to 5 years of utilization management experience.
Current RN license
Proven experience working in risk based integrated models of care.
Ability to use data to drive decisions and collaboration with internal and external stakeholders.
Strong strategic thinking, problem solving, and decision making skills.
Excellent communication and leadership abilities, capable of motivating and guiding teams toward timely and efficient care management strategies

Responsibilities

Rigorous adherence to PACE program service authorization policies, ensuring that participant care and related claims are: Reasonable and necessary for diagnosis or treatment and consistent with PCP coordination decisions.
In accordance with accepted medical standards and consistent with the participant care needs including level of care and advanced care planning principles.
Active involvement in various aspects of the utilization management process, including: Concurrent review of all hospital admissions (observation and inpatient) with the Interdisciplinary Team driving efficient and timely transitions of care, retrospective review of inpatient admissions under 48 hours, and claims submitted inconsistent with the service authorization.
Concurrent review of all subacute and SNF admissions with the Interdisciplinary Team driving efficient and timely discharge plans and transitions of care.
Coordination and review of all other services delivered by contracted providers and identified by the PACE program assuring consistency with Interdisciplinary Team service authorization, care plans, and PCP coordination decisions.
Employ effective use of knowledge, critical thinking, and skills to: Advocate quality care and enhanced quality of life
Advocate decreased hospital stay when appropriate
Maintain accurate records of all patient related interactions
Appeal Management - In cases of claim rejection, the Intus Care Utilization Management Nurse will lead the provider appeals process. Responsibilities Include: Comprehensive review of provider network appeals.
Collaboration with the PACE Program's Medical Director to review and respond to appeal requests, ensuring issuance of a written determination consistent with the PACE program policies.