Rn Utilization Management Reviewer Jobs

Managed care experience or Case Management experience.

Provide utilization management as needed to ensure coordination of health care delivery.

Identify members at risk and refers for Care management and/or disease management as needed.

RN with an active, unrestricted nursing license (Concurrent Review, Medical Management, etc.)

Effectively able to screen and stratify members who are appropriate for care management services.

Ability to create and execute care management care plans and document per EH’s policies and procedures.

Position is responsible for review of clinical documentation of home care clinicians after admissions, recertifications, resumptions of care and discharge.

Minimum of 3 years of certified home care experience

Experience in OASIS review and coding highly desirable

Utilize decision software to assure OASIS assessment is completed accurately

Follows PDGM guidelines regarding coding with accuracy

Coach clinical staff on documentation accuracy

Minimum 1 year Utilization Management Experience

Intermediate to advanced computer skills and experience with Microsoft Suite, Word, Excel, Outlook.

Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.

Manager will travel twice a year to South Florida to attend meetings (See Additional Information below)

Minimum 1 year experience with any of the following Team Leadership, Project Leadership, or Subject Matter Expert, SME

Minimum 1-year progressive clinical experience preferably in an acute care clinical setting

3+ years combined clinical and utilization management experience

Experience with utilization management platform preferred

Knowledge, Skills & Abilities Required:

Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy

3+ years' experience working in a health plan preferred

Strong collaboration and negotiation skills

A minimum of three years utilization management experience working with individuals with complex care needs experience preferred.

Organization and time management skills are essential.

Utilizes nursing experience and judgment in addition to the client specific guidelines when determining medical necessity and quality check dates.

A minimum of three years clinical nursing experience preferred.

Intermediate level skills in Microsoft applications (Excel, Word, Outlook, and Windows environment).

Excellent verbal and written communication skills.

Provides education regarding utilization management activities and processes to members, caregivers, providers, and their administrative staff.

Experience in insurance, managed care and utilization management preferred.

Participates in Utilization Management auditing (i.e. Utilization Management Inter-reviewer reliability and denial files).

Supports Utilization Management department programs and goals through active participation.

Identifies and screens candidates for Case Management intervention and determines appropriate level of care from Utilization Management criteria.

Performs other duties and responsibilities as assigned.

What are the top 5 skills/requirements this person is required have?

Required Skill 3: Ability to apply clinical knowledge to adverse event data collection and data assessment.

Required Skill 1: Competent understanding of ICH/FDA regulations and guidelines affecting drug / device safety issues preferred.

Required Skill 2: Strong critical thinking skills

Required Skill 4: Ability to present accurate and medically sound safety data, both orally and in writing.

Length of the assignment: 1 year possible extension

Experience in Utilization Management or audit.

5 years clinical experience to include implementing or administering managed care or quality assurance activities.

Knowledge and understanding of associated state and federal guidelines

This role is telecmmute,100% remote

Registered Nurse (RN) with current unrestricted license in good standing in state of operations.

Ability to work alone in a fast paced, demanding environment and impacting members.

Experience in utilization review and/or utilization management

Collaborate with UnitedHealthcare Medical Directors on performing utilization management

Follow all Standard Operating Procedures in end-to-end management of cases

Experience in acute, long-term care, acute rehabilitation, or skilled nursing facilities

Apply clinical expertise when discussing case with internal and external Case Managers and Physicians

Identify delays in care or services and manage with MD

2 or more years of clinical experience preferably in an acute care, skilled or rehabilitation clinical setting

Comprehensive knowledge of Microsoft Word, Outlook and Excel

Previous Medicare/Medicaid Experience a plus

Call center or triage experience

Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment

Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.

Submits appropriate documentation/clinical information in enterprise platform systems record keeping and documentation requirements.

Maintains awareness and complies with Plan CHC authorization timeliness standards based on DHS/NCQA requirements.

Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).

Verifies and documents Participant eligibility for services.

Accessing and applying Medical Guidelines for decision making prior to Medical Director/Physician Advisor referral.

Assist with special projects and specialty duties/responsibilities as assigned by Management.

Utilization Review or Case Management experience.

Provide education to non-medical staff through discussions, team meetings, classroom participation and feedback.

Knowledge of specific criteria/protocol sets and the use of the same.

Working knowledge of word processing software.

Demonstrated customer service and organizational skills.

Participates/oversees special projects as requested by management.

Working knowledge of managed care and various forms of health are delivery systems.

Continuing education funds for additional certifications and certification renewal.

Maintains working knowledge of unit functions and ability to interpret to new hires, department innerworkings and workflow.

Acts as resource for staff/external entities troubleshooting as well as resolving issues. Keeps manager informed of any problems/issues that need resolving.

Strong clinical experience to include home health, rehabilitation, AND/OR broad medical surgical experience.

Assist with special projects and specialty duties/responsibilities as assigned by Management.

Provide education to non-medical staff through discussions, team meetings, classroom participation and feedback.

Knowledge of specific criteria/protocol sets and the use of the same.

Working knowledge of word processing software.

Demonstrated customer service and organizational skills.

Demonstrated oral and written communication skills.

Do you value care management and quality improvement?

Are you an experienced Clinical Reviewer looking for a new challenge?

Performs ongoing reassessment of review process to offer opportunities for improvement and/or change.

Active unrestricted RN applicable State and/or Compact State clinical license per contract requirements.

Knowledge of current NCQA/URAC standards strongly preferred.

Medical record abstracting skills required.

Establishing Care Management accountabilities and holding those resources accountable

Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:

Two years of prior experience with Utilization Management.

Previous training and demonstrated competence in negotiations, Quality Assurance, and Case Management outcomes.

CCM certification is a plus.

Ability to successfully manage conflict, negotiating “win-win” solutions.

1 year of Utilization Management experience

Responsible for certification determinations and sending written authorizations to referring physician and home health care provider.

Facilitates timely discharges and transfers based on individual needs and care requirements.

Certifications relevant to wound care such as WOCN or CWS required

Job Family: Medical and Clinical

Date Posted: Jun 01, 2023

Assist with special projects and specialty duties/responsibilities as assigned by Management.

Provide education to non-medical staff through discussions, team meetings, classroom participation and feedback.

Knowledge of specific criteria/protocol sets and the use of the same.

Working knowledge of word processing software.

Demonstrated customer service and organizational skills.

Demonstrated oral and written communication skills.

QA data management and strategic planning for upcoming needs

Competitive salary based on your experience and skills – we believe the top talent deserves the top dollar

Manage structured QA audits and subsequent remediation

Registered nurse with minimum of 3 years of clinical experience

Excellent organizational skills with the ability to multi-task and pivot with organizational needs.

Work closely with Clinical Training to identify and remediate RNs/APPs QA within weeks 4 through 12 of new hire orientation

Assist with special projects and specialty duties/responsibilities as assigned by Management.

Provide education to non-medical staff through discussions, team meetings, classroom participation and feedback.

Knowledge of specific criteria/protocol sets and the use of the same.

Working knowledge of word processing software.

Demonstrated customer service and organizational skills.

Demonstrated oral and written communication skills.