Job Description
Job Description
Job Description
UTILIZATION MANAGEMENT RN
There’s no place like Liberty Health
Come explore career opportunities with Liberty Health , a dynamic leader in the healthcare industry. Join us!
We are currently seeking an experienced:
UTILIZATION MANAGEMENT RN
JOB SUMMARY:
- Day-to-day management of Utilization Management queues, dashboards, members, ensuring all Utilization Management activities, which include authorization timeliness, discharge planning, adherence to policies and procedures to ensure high quality and cost-effective utilization management services.
- Ability to work decision letters timely and accurately
- Quality monitoring focusing on medical necessity guidelines and discharge planning opportunities to lower levels of care
- Assist the Director of Utilization Management with the Utilization Management Reports to be reviewed by Executive Leadership.
- Ability to contribute to the UM team to ensure compliant execution of UM program
- Review admissions and service requests for the following:
- Authorization requests to ensure appropriate care for members and within clinical guidelines
- Monitor members both inpatient/outpatient – provide updates to Director of Utilization Management and the clinical care teams
- Recommend more appropriate care if required
- Assess and coordinate discharge planning with Care Team.
- Assist co-workers with issues related to coding, medical records/documentation, pre-certification reimbursement and claim denials/appeals.
- Use critical thinking and problem-solving to navigate through the complexities of a member’s health conditions while maintaining coverage within the program guidelines.
- Ability to focus on interventions for improvement
- Provides appropriate responses to providers regarding UM questions or direct these questions to the Director of Utilization Management
- Monitors utilization management queues and dashboards, assuring compliance with reporting and turnaround times.
- Participates in the interdisciplinary approach to support continuity of care
- Participates in the Case Management processes and assists with the development of case management programs
- Ability to participate and contribute with the written policies and procedures and workflows
- Ability to participate in the On-Call rotation to ensure timeliness is maintained
- Ability to work occasional after hours to ensure timeliness is maintained.
- Contribute to and attend UM meetings and UM huddles.
- Other duties as assigned
- Less than 10% travel to the corporate office for Department meetings
JOB REQUIREMENTS:
- Licensed Registered Nurse credentialed from an accredited school/college with 3–5 years of clinical experience
- Maintain Active Registered Nurse License, (Compact, RN preferred)
- 1–5 years managed care Utilization Management experience (preferably with a Health Plan)
- Demonstrated experience in health plan utilization management, initial reviews, facility concurrent review discharge planning, and case management required.
- Medicare Advantage experience required
- Experience with InterQual or MCG authorization criteria preferred.
- Excellent computer skills and the ability to learn new systems are required.
- Strong attention to detail, organizational skills, and interpersonal skills are required.
- Demonstrated ability to problem-solve and manage professional relationships.
- Healthcare industry knowledge
- Excellent listening, verbal, written and interpersonal communication skills.
- High level of professionalism and confidentiality, with a strong customer focus.
- Can adapt well to operational needs with excellent follow-up skills.
- Must be self-motivated, with a work ethic of dedication and the discipline to work independently.
- Must have a valid driver’s license.
- Proven ability to communicate concisely and confidently with all staff levels. Clearly communicates instructions to remote users.
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Background checks/drug-free workplace.
EOE.
PI37c62849df58-25405-39262082
Job Tags
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