Utilization Review Nurse- Remote
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. In partnership with nursing home operators, the plans manage medical risk by improving patient care and reducing emergency room visits and avoidable hospitalizations. 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 medical services in compliance with medical and regulatory guidelines. This is a remote position.
Requirements
- At least one year of utilization management experience with a health plan or hospital-based UM department, including use of InterQual or MCG.
- Current, active, 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.
- Excellent customer service experience.
- Strong oral and written communication skills, including active listening.
- Ability to navigate multiple computer applications proficiently.
- Critical-thinking, problem-solving, and decision-making skills, including the ability to make decisions under pressure.
- Ability to manage multiple priorities, work independently and as part of a team, and work congenially with a wide variety of people.
- Self-motivated, with independent discretion and decision-making ability.
- Maintain privacy and confidentiality and demonstrate professionalism.
- Successfully complete required training.
- Encourage a supportive atmosphere attentive to patients’ personal and healthcare needs.
- Develop collaborative relationships with providers and educate them on levels of care.
- Ensure the integrity and high quality of utilization management services.
Nice To Haves
- Clinical experience.
- Current Certified Case Manager (CCM) credential.
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 based on members’ medical needs.
- Contact requesting providers, including specialty physicians, ancillary providers, and institutions, to gather necessary clinical data.
- Apply clinical review criteria, guidelines, and screens to determine the medical necessity of services based on available clinical data.
- Certify cases that meet applicable clinical review criteria, guidelines, and 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.
- Notify the Director of Medical Management or designee of potential risk management issues in a timely manner.
- Perform other duties as assigned.
Benefits
- Affordable medical, dental, and vision insurance options.
- Generous paid time off program and paid holidays for full-time staff.
- 24/7/365 access to doctors through TeleDoc.
- Optional short-term and long-term disability plans.
- Employee Assistance Plan (EAP).
- 401(k) retirement accounts with company match.
- Employee referral bonus program.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
