Utilization Management Rn (Remote)

Our mission is Better Health. Our passion is helping others.

What’s Your Why?

• Do you have a passion for helping others achieve Better Health?
• Are you ready to join a growing team that shares your mission?
• Are you looking for a career opportunity that will help you grow personally and professionally?

Why Join Our Team: At Votion, it’s our commitment, our passion, and our culture that sets us apart. Our Team Members make a difference each and every day! We don’t just talk the talk - we believe in it and live by it. Our core value is always to deliver 5-star service. And by doing so, we successfully achieve our mission of Better Health. We support our providers with all the necessary tools and resources they need to deliver the care all patients deserve. Be part of a team that is rebuilding sick care into Better Health Care. We take great care of our team, patients, providers, and affiliates because together, we can achieve: Better Care. Better Outcomes. Better Health.

THE OPPORTUNITY

We are currently searching for a competitive, self-motivated, and enthusiastic team member to work with the Health Services team! As a part of this team, you should have excellent organizational skills, and an outgoing personality, and must be results-oriented, self-managed, and motivated. The ability to work in a high-energy, fast-paced environment, along with strong attention to detail and relationship-building skills are essential. Our team is responsible for building the relationships that allow us to continue shaping the future of healthcare!

Essential Functions and Responsibilities:

Our ideal Team Member will promote the mission, vision, and values of the organization, identify the quality of care issues and resolve them when possible. Identifying alternatives to care before admission and the ability to confirm care is medically necessary and rendered at the most appropriate level is crucial. Additionally, ensuring the selection of the provider is appropriate and within the preferred network if possible. Our standards are high and they have set us apart from our competitors! Our GOAL is to review admitted members within 24-48 hours of admission and establish an appropriate discharge plan; identify patients with possible discharges to LTAC/IPR and communicate information to the CMO or Physician Consultant.

Other duties include and are not limited to:

• Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources.
• Member (family) engagement
• Continue Stay review - for Patients with LOS higher than 10 days at the Hospital or LTAC/ IPR cases.
• Promote decreased length of hospital stays when possible.
• Review Clinical information for concurrent reviews, extending the length of stay for Inpatients as appropriate.
• Educate all members with Complex Illnesses to ensure that they are fully aware of their Plan of Care
• Establishing Care Management accountabilities and holding those resources accountable
• Promote cost-effective medical outcomes.
• Promote improved Quality of Care and/or Life.
• Maintain accurate records in the company database of all interventions and provide timely verbal communication with CMO and/or Physician Consultant.
• Support the Health Services department on QA/QI initiatives.
• Engaging the member and provider care team in Plan of Care discussions
• Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:
• Assist with the preparation of quarterly summary reports.
• Transplant Case Follow up
• Provide for Continuity of Care.
• Prevent Hospitalization when possible and appropriate.
• Pre-admission or Prospective Review for Elective procedures or surgeries, referring to the CMO and/or Physician Consultant for those that require additional expertise.
• Confirm appropriate levels of care are received by Patients.
• Identify Inpatient cases to be escalated to CMO or Physician Consultant where Observation Stay could have been used so Peer-to-Peer occurs with Hospitalist.

Qualifications & Licensure:

• Two years of prior experience with Utilization Management.
• Proof of successful completion of education requirements for a Nurse as defined by the state of Florida as well as proof of such licensure in good standing.
• Previous training and demonstrated competence in negotiations, Quality Assurance, and Case Management outcomes.
• CCM certification is a plus.

Skills, Abilities, and Professional Competencies:

• Ability to successfully manage conflict, negotiating “win-win” solutions.
• Empathy.
• Computer literacy on G-Suite products and database programs.
• Strong organizational, and task prioritization skills.
• Excellent relationship management skills.
• Ability to function with minimal supervision.
• Patient advocacy focus.
• Demonstrated ability to problem-solve complex, multifaceted, and emotionally charged situations.

Working Conditions and Environmental/Physical Demands:

• Ability to use a computer keyboard and mouse 8 hours per day.
• Ability to dial, answer, and talk on the phone for 8 hours per day.

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