Utilization Review Nurse

Career Center • Franklin, TN

8d

About The Position

American Health Plans, a division of American Health Partners Inc., owns and operates Institutional Special Needs Plans (I-SNPs) for seniors living in long-term care facilities. Working with nursing home operators, its Medicare Advantage plans manage medical risk by improving patient care, reducing emergency room visits, and avoiding preventable hospitalizations. The division operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Iowa, Idaho, Louisiana, and Indiana, with planned expansion into other states in 2025.

The Utilization Review Nurse assesses the medical necessity and quality of healthcare services through pre-service, concurrent, and retrospective utilization management reviews. The role provides clinical support to the Clinical Services Department and Medical Director to help ensure members receive appropriate services in compliance with medical and regulatory guidelines.

Requirements

• At least one year of utilization management experience with a health plan or hospital-based UM department, using InterQual or MCG.
• Current, active, and unrestricted Registered Nurse (RN) license.
• Broad knowledge of Medicare regulations and guidance.
• Training in clinical certification, utilization management, and URAC and NCQA principles, policies, and procedures.
• Strong knowledge of medical terminology and CPT, ICD-10, and HCPCS codes.
• Strong oral and written communication skills, including active listening.
• Proficiency navigating multiple computer applications.
• Critical-thinking, decision-making, and problem-solving skills.
• Ability to work independently and as part of a team, handle multiple priorities, and make decisions under pressure.
• Ability to work congenially with a wide variety of individuals and provide positive, engaging customer service.
• Self-motivation and independent discretion in decision-making.
• Ability to maintain confidentiality and professionalism and encourage an optimistic, warm, and attentive environment.
• Successful completion of required training.

Nice To Haves

• Clinical experience.
• Current Certified Case Manager (CCM) credential.
• Excellent customer service experience.

Responsibilities

• Assess the medical necessity, quality of care, level of care, and appropriateness of healthcare services for plan members.
• Identify placement settings that provide the lowest level of restriction and greatest level of autonomy consistent with members’ medical needs.
• Contact requesting providers, including specialty physicians, ancillary providers, and institutions, to obtain necessary clinical information.
• Apply clinical review criteria, guidelines, and screens to determine medical necessity based on the clinical data provided.
• Certify cases that meet clinical review criteria, guidelines, and/or screens.
• Consult with a physician when reviews do not meet clinical review criteria, guidelines, or screens.
• Refer cases to internal professionals, including case management and medical consultation, when indicated.
• Complete utilization management reviews within accreditation, contractual, and regulatory timeframes.
• Timely notify the Director of Medical Management or designee of potential risk management issues.
• Maintain privacy and confidentiality of records and information relating to residents, employees, and the facility.
• Develop and maintain collaborative relationships with providers and educate them about levels of care.
• Perform other duties as assigned.

Benefits

• Affordable medical, dental, and vision insurance options.
• Generous paid time off and paid holidays for full-time staff.
• 24/7/365 access to doctors through TeleDoc.
• Optional short- and long-term disability plans.
• Employee Assistance Plan (EAP).
• 401(k) retirement accounts with company match.
• Employee referral bonus program.

What This Job Offers

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