Utilization Management Registered Nurse
About The Position
At The Oncology Institute of Hope and Innovation, our mission is to provide compassionate and accessible cancer care. As an Oncology Utilization Management RN, you help ensure patients receive timely and appropriate treatment that supports our values of integrity, excellence, better together, and empathy. Your clinical expertise directly strengthens patient access to life saving care and supports the high standards that guide everything we do. JOB PURPOSE AND SUMMARY: Reporting directly to the Director of Utilization Management Compliance, the Oncology Utilization Management Registered Nurse is responsible for ensuring timely, high quality, and cost-effective therapeutic care to patients utilizing the TOI model in conjunction with our Mission, Vision, and Core Values. Your clinical care review determinations for our hematology and oncology patients will be instrumental in assuring patient access to life-saving care and supporting the value-based ideology of the practice
Requirements
- Strong verbal and written communication skills
- Ability to work independently, initiate, and successfully complete tasks
- Problem-solving aptitude and the ability to navigate challenging situations with sensitivity and professionalism
- Excellent analytical and critical thinking skills with attention to detail for decision-making and problem-solving
- Mastery of computer skills, including Word, Excel, Power Point and applicable electronic medical software programs
- Maintain regular attendance
- Ability to effectively present information and respond to questions
- BSN degree preferred
- Minimum of three years of experience in Utilization Management
- Current Registered Nurse license in good standing with the appropriate state regulatory body
- Oncology experience required
Responsibilities
- Review cases for laboratory orders and diagnostic studies/procedures to ensure completeness of supporting documentation
- Conduct pre-authorization review of services to ensure compliance with medical policy and contracts
- With the UM Medical Directors, utilize evidence-based and value-based clinical guidelines to make utilization management decisions
- Meet delivery timelines in notifying patients and providers of authorization decisions that are consistent with CMS, NCQA, and any other regulatory requirements
- Collaborate with nursing, eligibility, and authorization teams to facilitate continuity of care and optimal patient outcomes
- Maintain accurate documentation of utilization and case management activities and report on those regularly
- Collaborate with Claims teams to reconcile any issues of improper billing, coding, and potential under/overutilization.
- Adhere to practice policies and procedures, including compliance with HIPAA privacy and security requirements and all state, federal and plan regulatory mandates
- Cooperate with utilization management pharmacy initiatives to implement and promote proprietary preferred pathways
- Participate in quality improvement initiatives to enhance processes and service delivery
- Participating in process improvement/cost of health care initiatives
- Ensure workflow procedures and guidelines are clearly documented and communicated
- Interpret or initiate changes in guidelines/policies/procedures
- Collaborate across functionally to improve member outcomes
- Participate in Regulatory and Internal Audits.
- Live and exemplify TOI core values, providing outstanding customer service and promoting a positive experience for patients and staff members.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Industry
Ambulatory Health Care Services
Number of Employees
501-1,000 employees
