UM RN

HealthEdge•Remote,

1d•Remote

About The Position

HealthEdge is seeking a highly motivated Utilization Review RN. The role performs prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services to assess medical necessity, length of stay, intensity of service, and level of care. Reviews may include appeal requests initiated by providers, facilities, and members. Depending on the assignment, the RN may establish care plans and coordinate care across the health care continuum, including member outreach assessments. The RN reviews and authorizes service requests, applies approved clinical protocols, supports discharge planning, and coordinates with internal and external entities. The position also analyzes and documents retrospective reviews, appeals, quality-of-care issues, and patterns of care, while resolving matters involving benefits, eligibility, non-authorized services, and coordination of benefits. The role may include provider education and, with Provider Services, negotiation of reimbursement rates for non-contracted providers. This is a full-time, permanent remote position in the United States. The work may involve collaborating across multiple time zones in a hybrid or remote environment, extended periods at a computer using video technology, occasional movement around an office, and travel depending on company needs.

Requirements

Current unrestricted Registered Nurse license.
At least 2 years of clinical experience, which may include acute patient care, discharge planning, case management, or utilization review.
Demonstrated clinical knowledge and experience related to patient care and health care delivery processes.
Excellent written and verbal communication skills.
Excellent customer service and interpersonal skills.
Working knowledge of current Microsoft Office Suite PC applications.
Ability to apply clinical criteria and guidelines for medical necessity, setting or level of care, and concurrent patient management.
Knowledge of standard medical procedures and practices and their application, as well as current trends and developments in medicine and nursing, alternative care settings, and levels of service.
Knowledge of policies and procedures, member benefits, and community resources.
Knowledge of applicable accreditation standards and local, state, and federal regulations.

Nice To Haves

Case Management certification may be preferred depending on department assignment; certification or progress toward certification is highly preferred and encouraged.
At least 1 year of experience in a health insurance plan or managed care environment.

Responsibilities

Review, research, and authorize requests for elective, direct, ancillary, urgent, emergency, and other services.
Contact medical and support personnel to identify and recommend alternative treatments, service levels, and lengths of stay using approved clinical protocols.
Analyze, research, respond to, and prepare documentation for retrospective review requests and appeals in accordance with local, state, and federal regulations and applicable accreditation standards, such as NCQA.
Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities.
Analyze patterns of care associated with disease progression, identify contractual services, and organize their delivery through appropriate channels.
Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, and care coordination.
Identify and document quality-of-care issues, resolving them or routing them to the appropriate area.
Review out-of-area and out-of-network services and recommend patient transfers to in-network services or alternative care plans.
Develop and deliver targeted education for providers regarding policies, procedures, and benefits.
As needed and in conjunction with Provider Services, identify and negotiate reimbursement rates for non-contracted providers.
Perform other duties as assigned based on department assignment.