RN Utilization Review Care Manager PRN

Fully Remote

St. Marys Regional Hospital

Part time

R189124

The RN Utilization Review Care Management I leverages clinical expertise and critical thinking to perform utilization review care management screenings, assessments, and evaluations, with a strong focus on resource stewardship. This role involves developing and implementing plans that promote cost-effective, high-quality care. Collaboration with patients, their families or significant others, healthcare providers, insurers, and other involved parties is essential to ensure compliant, efficient, effective, and patient-centered utilization review services.

We are committed to offering flexible work options where approved and stated in the job posting. However, we are currently not considering candidates who reside or plan to reside in the following states:
California, Connecticut, Hawaii, Illinois, Massachusetts, Maine, Minnesota, New York, Pennsylvania, Rhode Island, Virginia Vermont, Washington.

Please note that a video interview through Microsoft Teams will be required.

• Shift coverage enterprise wide - Peaks/Canyons/Desert regions
• Average 2 days per week; 2 weekends per 8-week schedule
• Holiday coverage is also required
• RN Licensure with compact required
• 8:00 AM - 5:00 PM

• Reviews and investigates medical records and applies clinical expertise to assure appropriate benefit utilization and medical necessity as relates to requested services, authorization history, and treatment plan.
• Uses in-depth knowledge of medical procedures, treatments, and diagnosis to apply evidence-based guidelines (e.g. Inter Qual/MCG) and medical policies for prior authorization and post service reviews.
• Follows the applicable regulatory guidelines (NCQA, CMS, State, plan) and ensures timely review with clear and accurate communication to members and requesting providers. Adheres to regulatory guidelines and timely communication with members, providers, and internal/external partners.
• Based on medical necessity and clinical best practice, proactively engages with providers to ensure safe and efficient medical care, appropriate care setting, and safe transitions of care referring to alternate programs as applicable.
• Collaborates with physicians, internal staff, members, and families to assist in expediting the requested authorizations, and directs toward medically necessary care and the correct level/setting for services requested.
• Engage proactively with members and providers for safe, efficient care and transitions as applicable to continuity of care, redirection, and authorization determination.
• Resolves queries regarding authorizations, treatment plans, and medical necessity determinations.
• Mentors and guides the UM LPN & non-clinical on process/clinical questions and application of resources.

• Utilization Management
• Clinical Expertise
• Investigative Acumen
• Medical Diagnosis & Treatment
• Medical Terminology
• Time Management
• Problem Solving
• Quality Care
• Communication

• Current Registered Nurse (RN) license in state of practice, and compact licensure within service area.
• Bachelor of Science in Nursing (BSN) from an accredited institution (degree verification required). RNs hired or promoted into this role must obtain their BSN within four (4) years of hire or promotion date.
• Demonstrated experience in care management/navigation or closely related field including:
  Utilization Management, discharge planning, managed care, health promotion, health coaching, behavioral health, or Patient Educator job role.
• Demonstrated clinical nursing experience in an inpatient hospital setting, and familiarity with hospital patient-related terminology and processes.
• Demonstrated understand of disease management including treatment, length of stay, identifying barriers to delivery of care and any variation.
• Strong written, verbal communication and conflict resolution skills
• Basic computer hardware set-up, ability to customize computer settings and use multiple monitors and capable of independent troubleshooting internet and applications. Knowledge of Microsoft Office software.
• Ability to work independently, be self-motivated, have a positive attitude, and be flexible in a rapidly changing environment.
• Strong written, verbal communication and conflict resolution skills

• One (1) year experience in care management/navigation or closely related field including:
  Utilization Management, discharge planning, managed care, health promotion, health…