Description

JOB SUMMARY

The Utilization Management (UM) Nurse ensures quality of patient care, effective utilization of available health services, review of admissions for medical necessity, necessity of continued stay in the inpatient setting, and medical necessity for outpatient services. Ensures members have a safe discharge plan in place prior to discharge from the inpatient setting.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• Responsible for providing timely referral determination by accurate:
  • Usage of the Milliman Care Guidelines
  • Identification of referrals to the medical director for review
  • Appropriate letter language (i.e. – denials)
  • Appropriate selection of the in or out of network providers
  • Proper identification of eligibility and health plan benefits
• Maintain compliance in turnaround time requirements.
• Work closely with supervisor/lead to address issues and delays that can cause a failure to meet or maintain compliance.
• Meets or exceeds production and quality metrics.
• Work directly with the provider(s) and Medical Director to facilitate quality service to the member and provider.
• Identifies and refers members to the appropriate healthcare program (e.g. case management, disease management).
• Maintains and keeps in total confidence, all files, documents and records that pertain to the business operations.
• Collaborates, educates, and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria.
• All other job-related duties as it relates to the job function or as delegated by management.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred
• Proficient with Microsoft Word, Outlook, and Excel
• Medical Terminology preferred

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience preferred to perform the job.

• High School Diploma or GED
• 3-5 years of acute care experience
• 2 years Health Plan Utilization Review or equivalent
• 2 years managed care experience in UM/CM Department, preferred
• ICD-10 and CPT coding experience a plus
• Experience working in a health plan medical management documentation system a plus
• Experience in EZ-CAP preferred (California only)

REQUIRED CERTIFICATIONS/LICENSURE

Include minimum certification required to perform the job.

• Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN)
• Licensure must be current and unrestricted in the appropriate jurisdiction

PHYSICAL DEMANDS

The physical demands 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.

• Must be able to work in sitting position, use computer and answer telephone

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Office Work Environment

TRAVEL

• Approximately 5% travel may be required

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

Compensation and Benefit Information

Compensation

• Pay: $27.30 - $40.95 per hour. Compensation depends on location, qualifications, and experience.
• Position may be eligible for a signing bonus for qualified new hires, subject to employment status.
• Conifer observed holidays receive time and a half.

Benefits

Conifer offers the following benefits, subject to employment status:

• Medical, dental, vision, disability, and life insurance
• Paid time off (vacation & sick leave) – min of 12 days per year, accrue at a rate of approximately 1.84 hours per 40 hours worked.
• 401k with up to 6% employer match
• 10 paid holidays per year
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
• For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.