Utilization Management Nurse - JHP

Thomas Jefferson University • Philadelphia, PA

5d • Onsite

About The Position

The Utilization Management Nurse is responsible for ensuring cost-effective, quality utilization management in acute and post-acute inpatient settings for pediatric or adult populations, including skilled nursing facilities and rehabilitation. The nurse reviews clinical information provided by facilities and communicates utilization management determinations within required timeframes.

This role reviews and tracks emergency admissions, conducts concurrent and admission reviews using InterQual criteria, monitors cases for timely reviews and decisions, and requests and evaluates medical records to determine appropriate acute care days. Questionable days are referred to the medical director. The nurse serves as a liaison and resource for providers, members, physicians, primary care providers, and Utilization Review departments; identifies and helps address utilization trends; and contributes to documentation, tracking tools, process improvements, and cross-functional training. The role also includes after-hours on-call coverage and participation in relevant work groups.

The nurse is expected to complete assignments accurately and on time, maintain awareness of assignment status, and provide appropriate updates to the manager. Other duties may be assigned.

Requirements

• Active license to practice professional nursing in the Commonwealth of Pennsylvania as a Registered Nurse.
• 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 co-workers, members, and providers at owner institutions.
• Organized and detail-oriented, with the ability to handle 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).

Responsibilities

• Review and track emergency admissions to identify appropriate levels of care for acute and post-acute inpatient services.
• Perform concurrent and/or admission reviews on hospital admissions using InterQual criteria guidelines.
• Track assigned cases to ensure timely reviews, updates, decisions, and case documentation.
• Request and review medical records to identify appropriate acute care days; approve appropriate days or refer questionable days to the medical director.
• Act as a liaison between providers, members, and internal departments.
• Serve as a resource for physicians, primary care providers, Utilization Review departments, and medical providers.
• Identify hospital utilization trends during the review process and help resolve them.
• Maintain departmental and regulatory timeframes for utilization decisions.
• Contribute to the development and improvement of documentation, tracking tools, and process flows.
• Maintain collaborative cross-functional training within the Utilization Management Department.
• Provide after-hours on-call coverage and 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 objectives, maintain awareness of assignment status, and 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 per diem colleagues, adjunct faculty, and Jeff Temps

What This Job Offers

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