Utilization Management RN

Florida Blue

12h

About The Position

WebTPA, a GuideWell Company, is a healthcare third-party administrator with over
30+ years of experience building unique benefit solutions and managing
customized health plans.

What is your impact?
Utilization Management (UM) nurses will provide our clients with appropriate and
comprehensive utilization of health care services and benefits as designated.
This requires an experienced RN with a diverse clinical background, as well as
experience within the managed care industry and specifically in the self-funded
arena. The UM Nurse will work with providers, hospitals, members and clients to
achieve optimal outcomes through appropriate use of services and benefits.

What is your impact?

Pre-Certification of emergency, urgent and elective admissions, and the
determination of length of stay based on age, multiple or single diagnoses,
and the nature of the diagnosis. Medical record review to determine medical
necessity of requested services.
Concurrent review and the determination of the extension of the length of
stay based on the severity of illness and the intensity of service. Medical
record review to determine medical necessity of requested services.
Assist with Discharge Planning to ensure compliance with benefit plan and use
of preferred providers/networks. Steerage to high quality, cost-effective
domestic and in-network providers.
Identification of alternative treatment plans, which are to be approved by
all parties. These alternative care plans will be based on quality care
within cost containment guidelines allowing available claims dollars to be
used in the most judicious manner possible (10%)
Establishing identification of services, resources, providers and facilities
that could best serve clientele in a timely and cost- effective manner in
order to obtain optimum value for the client and reimbursement source.
Interpreting individual health plans and authorizing/coordinating care in
accordance with plan provisions.
Evaluate the cost effectiveness of the elected treatment plan,
pre-implementation and post- implementation. This outcome measurement will be
used in determining the effective results and in establishing future
patient-centered care plans.
Referral to appropriate care management resources (i.e. Medical Director,
Complex Case Management, and Chronic Condition Management teams).

Requirements

• 5+ years related work experience.
• Professional background in clinical nursing and patient assessment.
• Graduate of an accredited school of nursing. RN - Registered Nurse - Compact State Licensure in good standing.
• Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices.
• Ability to collaborate with cross-operational areas within the organization.
• Good verbal and written communication skills.
• Ability to work as a team member, effectively and collaboratively, with non-clinical teammates.
• Maintaining client's privacy, confidentiality and safety as well as acting as an advocate for the covered member.
• Adherence to ethical, legal and accreditation/regulatory standards.
• Ability to identify problems such as underutilization or overutilization of services
• Ability to promote and maintain quality care through analysis

Nice To Haves

• Bachelor’s degree in nursing preferred
• Intensive care or higher-acuity patient experience preferred.
• Prior experience in utilization management or case management preferred, preferably within the managed care environment.
• Proficiency in maintaining good rapport with other staff members, physicians, health care facilities, clients, and providers.
• Knowledge of managed care in a self-funded employer population is preferred.

Responsibilities

• Pre-Certification of emergency, urgent and elective admissions, and the determination of length of stay based on age, multiple or single diagnoses, and the nature of the diagnosis. Medical record review to determine medical necessity of requested services.
• Concurrent review and the determination of the extension of the length of stay based on the severity of illness and the intensity of service. Medical record review to determine medical necessity of requested services.
• Assist with Discharge Planning to ensure compliance with benefit plan and use of preferred providers/networks. Steerage to high quality, cost-effective domestic and in-network providers.
• Identification of alternative treatment plans, which are to be approved by all parties. These alternative care plans will be based on quality care within cost containment guidelines allowing available claims dollars to be used in the most judicious manner possible (10%)
• Establishing identification of services, resources, providers and facilities that could best serve clientele in a timely and cost- effective manner in order to obtain optimum value for the client and reimbursement source.
• Interpreting individual health plans and authorizing/coordinating care in accordance with plan provisions.
• Evaluate the cost effectiveness of the elected treatment plan, pre-implementation and post- implementation. This outcome measurement will be used in determining the effective results and in establishing future patient-centered care plans.
• Referral to appropriate care management resources (i.e. Medical Director, Complex Case Management, and Chronic Condition Management teams).

Benefits

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, short- and long-term disability programs
• Leave programs to support personal circumstances.
• Retirement Savings Plan includes employer contribution and employer match
• Paid time off, volunteer time off, and 11 holidays
• Additional voluntary benefits available and a comprehensive wellness program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level