Utilization Management RN - Jefferson Health Plan

Jefferson Health Plans • Jefferson Township, PA

7d • Onsite

About The Position

The Utilization Management Nurse is responsible to assure cost-effective, quality utilization management in the acute level of care setting for the pediatric or adult population in the post-acute inpatient setting (i.e., SNF/Rehab). Also, responsible to review clinical information provided by facilities and communicates UM determinations maintaining timeliness. Work under general supervision of manager and team lead to assure cost-effective, quality patient care management for DME, homecare (acute skilled nursing and therapy services), home infusion, hospice at home, transportation, and Shift care (private duty home health for pediatric medically complex members). This role interacts with co-workers, visitors, and other staff consistent with the values of Jefferson. The role involves reviewing and tracking emergency admissions to identify appropriate level of care for acute and post-acute inpatient services, performing concurrent review and/or admission review on all hospital admissions using InterQual criteria guidelines, and tracking assigned cases for timely reviews/updates and decisions as reflected in case documentation. The Utilization Management Nurse will request and review medical records to identify appropriate acute care days and approve or refer questionable days to the medical director for decision. This role functions as a liaison between providers, members and interdepartmentally, serving as a resource for physicians, PCPs, Utilization Review departments and all medical providers. The role also identifies trends that impact on utilization at hospitals during the review process and helps resolve them, while maintaining departmental and regulatory timeframes for utilization decisions. Contributions to the development and enhancement of documentation, tracking tools and process flows are expected, as is maintaining collaborative and effective cross-functional training within the Utilization Management Department. Utilization management performs after-hour on-call coverage. Participation in relevant work groups and providing deliverables as necessary, along with successful and timely completion of assignments in accordance with departmental and Company operational objectives and seeking feedback on performance, are key aspects of this role. Ensuring that assignments are scheduled and completed in an accurate and timely manner, and maintaining detailed knowledge of the status of all assignments and routinely updating the manager, as appropriate, are also required. The role is responsible for after-hour on-call shifts as needed and performs all other duties as assigned.

Requirements

• Graduate of an accredited nursing program (Associate’s or Bachelor’s degree in Nursing).
• Minimum of 2-3 years of clinical nursing experience.

Nice To Haves

• BSN preferred.
• At least 1 year of utilization management, case management, or managed care experience preferred.

Responsibilities

• Assure cost effective, quality utilization management in the acute level of care setting for the pediatric or adult population in the post-acute inpatient setting (i.e., SNF/Rehab).
• Review clinical information provided by facilities and communicates UM determinations maintaining timeliness.
• Assure cost-effective, quality patient care management for DME, homecare (acute skilled nursing and therapy services), home infusion, hospice at home, transportation, and Shift care (private duty home health for pediatric medically complex members).
• Review and track emergency admissions to identify appropriate level of care for acute and post-acute inpatient services.
• Perform concurrent review and/or admission review on all hospital admissions using InterQual criteria guidelines.
• Track assigned cases for timely reviews/updates and decisions as reflected in case documentation.
• Request and review medical records to identify appropriate acute care days and approve or refer questionable days to the medical director for decision.
• Function as a liaison between providers, members and interdepartmentally.
• Serve as resource for physicians, PCPs, Utilization Review departments and all medical providers.
• Identify trends that impact on utilization at hospitals during the review process and help resolve them.
• Maintain departmental and regulatory timeframes for utilization decisions.
• Contributes to the development and enhancement of documentation, tracking tools and process flows.
• Maintains collaborative and effective cross-functional training within the Utilization Management Department.
• Perform after hour’s on-call coverage.
• Participates in relevant work groups and provide deliverables as necessary.
• Successful and timely completion of assignments in accordance with departmental and Company operational objectives and seeks feedback on performance.
• Ensures that assignments are scheduled and completed in an accurate and timely manner.
• Maintains detailed knowledge of the status of all assignments and routinely updates the manager, as appropriate.
• Responsible for after hour on call shifts as needed.
• Performs all other duties as assigned.

Benefits

• Medical (including prescription)
• Supplemental insurance
• Dental
• Vision
• Life and AD&D insurance
• Short- and long-term disability
• Flexible spending accounts
• Retirement plans
• Tuition assistance
• Voluntary benefits
• Tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree