What are the responsibilities and job description for the Utilization Management Nurse position at Guidewell?
Job Summary
All Utilization Management (UM) nurses will provide our clients with appropriate and comprehensive utilization of health care services and benefits as designated. This requires an experienced RN/LVN with a diverse clinical background, as well as experience within the managed care industry and specifically in the self-funded arena. The UM Nurse will work with providers, hospitals, members and clients to achieve optimal outcomes through appropriate use of services and benefits.
All Utilization Management (UM) nurses will provide our clients with appropriate and comprehensive utilization of health care services and benefits as designated. This requires an experienced RN/LVN with a diverse clinical background, as well as experience within the managed care industry and specifically in the self-funded arena. The UM Nurse will work with providers, hospitals, members and clients to achieve optimal outcomes through appropriate use of services and benefits.
Essential Functions
- The essential functions listed represent the major duties of this role, additional duties may be assigned.
- Pre-Certification of emergency, urgent and elective admissions and the determination of length of stay based on age, multiple or single diagnoses, and the nature of the diagnosis.
- Concurrent review and the determination of the extension of the length of stay based on the severity of illness and the intensity of service.
- Assist with Discharge Planning to ensure compliance with benefit plan and use of preferred providers/networks.
- Identification of alternative treatment plans, which are to be approved by all parties. These alternative care plans will be based on quality care within cost containment guidelines allowing available claims dollars to be used in the most judicious manner possible.
- Assessment of the clinical status and resultant sequel to coordinate the most appropriate service to meet the individual’s health care needs. The UR Nurse will then monitor the health status and the impact of the health plan for each client. The UR Nurse will be responsible for altering the care plan as deemed appropriate by the dynamic, ever-changing client needs.
- Establishing identification of services, resources, providers and facilities that could best serve clientele in a timely and cost- effective manner in order to obtain optimum value for the client and reimbursement source.
- Evaluate the cost effectiveness of the elected treatment plan, pre-implementation and post- implementation. This outcome measurement will be used in determining the effective results and in establishing future patient-centered care plans.
- Steerage to high quality, cost-effective domestic and in-network providers.
- Referral to appropriate care management resources (i.e. Medical Director, Complex Case Management, and Chronic Condition Management teams).
- Accurate and timely reporting as deemed appropriate by each client member.
- Medical record review to determine medical necessity of requested services.
- Interpreting individual health plans and authorizing/coordinating care in accordance with plan provisions.
- Maintaining client’s privacy, confidentiality and safety as well as acting as an advocate for the covered member.
- Adherence to ethical, legal and accreditation/regulatory standards.
Required Work Experience
2 years related work experience. Experience Details: utilization management or case management preferred, preferably within the managed care environment
2 years related work experience. Experience Details: utilization management or case management preferred, preferably within the managed care environment
Required Management Experience
No supervisory/management experience required
No supervisory/management experience required
Required Education
Related Bachelor's degree required graduate of an accredited school of nursing
Related Bachelor's degree required graduate of an accredited school of nursing
Required Licenses and Certifications
RN - Registered Nurse - State Licensure And/Or Compact State Licensure LVN state license. (Multi-state license if living in a nurse compact state.)
RN - Registered Nurse - State Licensure And/Or Compact State Licensure LVN state license. (Multi-state license if living in a nurse compact state.)
Additional Required Qualifications
Professional background in clinical nursing and patient assessment.
Prior experience in utilization management or case management preferred, preferably within the managed care environment.
Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery of quality health care services and cost containment practices.
Proficiency in maintaining good rapport with physicians, health care facilities, clients and providers.
Good verbal and written communication skills.
Ability to effectively and collaboratively work as a team member with non-clinical teammates.
Knowledge of managed care in a self-funded employer population would be beneficial.
Assertiveness, self-motivation and a sense of responsibility are a must.
Professional background in clinical nursing and patient assessment.
Prior experience in utilization management or case management preferred, preferably within the managed care environment.
Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery of quality health care services and cost containment practices.
Proficiency in maintaining good rapport with physicians, health care facilities, clients and providers.
Good verbal and written communication skills.
Ability to effectively and collaboratively work as a team member with non-clinical teammates.
Knowledge of managed care in a self-funded employer population would be beneficial.
Assertiveness, self-motivation and a sense of responsibility are a must.
General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
Physical/Environmental Activities
Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally
We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.
Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally
We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.
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