Utilization Management Nurse

Curana Health, Inc.•Remote,

1d•Remote

About The Position

The Utilization Management Nurse reviews and monitors members’ use of health care services to support high-quality, cost-effective care. The position applies medical and utilization expertise to evaluate the appropriateness and efficiency of medical services and procedures, including prior authorizations, concurrent reviews, proactive discharge and transition planning, and high-dollar claims reviews. The work has a strong emphasis on concurrent review and transition planning for members in hospitals and skilled nursing facilities. This is primarily a remote, telephonic position with normal business-day hours and coverage for one weekend day per month. The nurse serves as a liaison to the Plan Medical Director and works closely with appeals and medical decisions. The role also coordinates with providers, members, facilities, and internal teams to support continuity of care, appropriate authorizations, quality improvement, and cost-effective outcomes.

Requirements

At least 2 years of clinical experience as an RN, LPN, or LVN.
Demonstrated experience in health plan utilization management, facility concurrent review discharge planning, and transfer coordination.
Active, unrestricted nursing license.
Excellent computer skills and ability to learn new systems.
Strong attention to detail, organizational skills, and interpersonal skills.
Demonstrated ability to problem-solve and manage professional relationships.

Nice To Haves

At least 1 year of managed care or equivalent health plan experience.
Medicare Advantage experience.
Experience with InterQual or MCG authorization criteria.

Responsibilities

Perform concurrent and retrospective reviews of facility and appropriate home health services, monitoring the level and quality of care.
Proactively manage acutely and chronically ill patients to improve quality outcomes and decrease costs.
Evaluate members’ discharge plans and provide feedback to providers about available covered services and potentially more appropriate levels of care.
Determine observational versus acute inpatient status as part of the hospital prior authorization process.
Engage proactively with members’ providers in discharge and transition planning as part of the concurrent review process.
Participate in clinical utilization review notification processes with facilities; prepare CMS-compliant notification letters for non-certified and negotiated days within established time frames; and review non-certification files for correct documentation.
Maintain accurate records of communications.
Monitor utilization reports for compliance with reporting requirements and turnaround times.
Address care issues with the Director of Quality and Care Management and the Chief Medical Officer or Medical Director, as appropriate.
Coordinate an interdisciplinary approach to support continuity of care.
Provide utilization management, transition coordination, discharge planning, and appropriate authorizations for covered services to providers and members.
Coordinate identification and reporting of potential high-dollar or high-utilization cases for appropriate reserve allocation.
Identify and recommend opportunities to reduce costs and improve quality of care across the continuum.
Clarify health plan medical benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies.
Identify members early for potential inclusion in a Chronic Care Improvement Program.
Assist in identifying and reporting potential quality-of-care concerns and ensure they are reported to the Quality Improvement Department.
Work as an interdisciplinary team member within Medical Management and across departments.
Perform other duties as assigned.