Registered Nurse; RN - Utilization Management Review - Days- Remote

Licensure & Certification Requirements

Licensed Registered Nurse in the State of Virginia or eligible
Current RN licensure in Virginia

• Minimum of three (3) years of nursing experience in an acute care setting
• One (1) year of Care Coordination experience
• Two (2) to Four (4) years of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc.)
• Proficient in Milliman Care Guidelines (MCG) or Inter Qual criteria for medical necessity, setting and level of care, and concurrent patient management

• Bachelor of Science in Nursing from an accredited School of Nursing (REQUIRED)
• Master’s Degree in Nursing or a healthcare related field from an accredited program (PREFERRED)
• Case Management Certification (PREFERRED)

• Conduct prospective, concurrent and retrospective utilization review for inpatient services, observations, and specific outpatient service requests
• Perform reviews of current inpatient services to determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination
• Work with attending and consulting physicians to facilitate effective and efficient transition through the hospitalization process
• Collaborate with multidisciplinary team members to ensure patient needs are met and care delivery is coordinated across the continuum, while ensuring resources are efficiently utilized and appropriate reimbursement is achieved
• Utilize medical necessity criteria to assess appropriateness of level and setting of care, assist in denial and appeals processes, assess quality, and identify and report potential risk management issues
• Participate in and complete all patient safety initiatives appropriate to the position
• Establish and maintain professional rapport with providers, patients/families, and internal customers
• Train and educate new UM staff nurses and new RN Care Coordinators, providing technical instruction, leadership, and performance coaching

• Ability to flex the schedule as needed to meet the demands of the department

Physical Lifting 20-50 lbs.

Activities:

Prolonged sitting, Repetitive motion
Mental/Sensory:
Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking
Emotional:
Fast pace environment, Steady pace, Able to handle multiple priorities, Frequent and intense customer interactions, Able to adapt to frequent change

EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.