Um Rn Jobs

Job Summary
The Utilization Management nurse works within a multidisciplinary team to help identify and manage members who are in need of additional care or support in their home to improve their quality of life. The Utilization Management nurse will assess and process all authorization requests to determine medical necessity to ensure all care services, member education, and preventative interventions are maintained.
Primary Responsibilities

• Participates in on call scheduling
• Authorization of medically necessary services in coordination with the care management department. Review of care management documentation and outcomes evaluation to ensure member receives services and supports required to meet psychosocial, educational and health care needs
• Recognizes quality of care issues and escalates the issues appropriately
• Provides utilization review for preauthorization, concurrent and discharge reviews and post service review
• Participates in other meetings as requested
• Interacts with providers and facilities in a professional, respectful manner
• Participates in quality improvement initiatives
• Other duties as assigned
• Ensures that the services required for the plan of care is met in partnership with the person centric process which may include his/her significant other, primary caregiver, the primary and attending physicians, and various other providers and support involved in the member’s care.
• Apply medical necessity guidelines based on appropriate criteria
• Assists members with the coordination of services from various settings as appropriate
• Utilizes knowledge of community resources and the member’s benefit structure
• Have a knowledge of the Appeals and Grievances process
• Participates in case rounds as a member of the Integrated Care Team
• Complies with all CPHL’s standards for documentation

Education And Experience
Type of Experience
Required

• Strong written and verbal communication skills
• Minimum 2 years utilization management experience
• Ability to travel within assigned area
• Active and unrestricted NYS RN license

Preferred

• Bachelor of Science in Nursing
• Knowledge of Milliman or InterQual criteria
• CCM certification

Preferred

• Experience working within a managed care environment

Specific Technical Skills
Preferred: Computer proficiency
SCOPE INFORMATION
# Direct Reports: 0
Physical Requirements
The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification. They should not be construed as an exhaustive list of all responsibilities, duties and skills required
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