Utilization Management RN Nurse - Remote

Description:

JOB SUMMARY

The purpose of the Utilization Management Nurse is to ensure quality of patient care, effective utilization of available health services, review of admissions for medical necessity and necessity of continued stay in the inpatient setting. 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 and coding (denials, deferrals, modifications)
  • Appropriate selection of the preferred and contracted providers
  • Proper identification of eligibility and health plan benefits
  • Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out
• Responsible for maintaining compliance in turnaround time requirements as mandated by the TAT Standards
• Responsible for working closely with supervisor/lead to address issues and delays that can cause failure to meet or maintain compliance.
• Meets or exceeds production and quality metrics.
• Work directly with the provider(s) and health plan Medical Director to facilitate quality service to the member and provider.
• Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management).
• Attend all mandatory meetings and training.
• 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 the management team.

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 accommodation may be made to enable individuals with disabilities to perform the essential functions.

• Two (2) years managed care experience in UM/CM Department, preferred
• Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred
• ICD-9 and CPT coding experience a plus
• Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
• Experience in EZ-CAP preferred
• 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.

• Minimum Education: RN
• Preferred Education: BA or BS in Nursing
• Minimum Experience: 3 to 5 years of acute care experience
• 2 Years Health Plan Utilization Review or equivalent
• Preferred Experience: 5 years Health Plan Utilization Review
• 5 years Acute Care experience with 1 year ICU / ER

REQUIRED CERTIFICATIONS/LICENSURE

Include minimum certification required to perform the job.

• 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 accommodation 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
• Ability to travel
• Includes ability to walk through hospital-based departments across broad campus settings, including Emergency Department environments

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation 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: $30.85 - $46.28 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.