Utilization Management Nurse

The Utilization Management (UM) Nurse will have well-developed knowledge and skills in utilization management, medical necessity, and care coordination. This individual is responsible for performing a variety of prospective, concurrent, and retrospective UM-related activities. The UM nurse’s role is to ensure that healthcare services are administered with quality, cost efficiency, and within compliance and regulation standards. The UM Nurse is also responsible for participating in initial clinical review.

• Performs prospective, concurrent, and retrospective medical necessity reviews for healthcare products and services utilizing appropriate clinical criteria and/or evidence-based guidelines.
• Performs level of care (LOC) determinations and monitors length of stay based on severity of illness and intensity of service using the appropriate clinical criteria.
• Conducts initial clinical review (in accordance with accreditation, laws, and regulations).
• Ensures regulatory and/or accreditation guidelines are met for timeliness of medical necessity reviews.
• Verifies accuracy of codes and services and applies them accurately with appropriate documentation.
• Coordinates discharge planning needs and transition of care with the registered nurse case managers and other healthcare team members, as deemed appropriate.
• Communicates member, provider, and facility notifications, citing clinical criteria and Medical Director denial rationale, when indicated.
• Collaborates with a multi-disciplinary staff and interdepartmentally.
• Establishes and maintains professional relationships with providers and facilities to establish a smooth operational flow of authorizations and referrals.
• Evaluates, coordinates, manages, and documents all UM-related activities.
• Maintains current knowledge of medical necessity criteria and UM-related policies and procedures.
• Assists in the development and maintenance of medical necessity criteria and clinical pathways.
• Participates in the monitoring of the effectiveness and outcomes of the UM program.
• Participates in UM program process improvement initiatives.
• Complies with all regulatory and accreditation standards related to utilization management and/or case management.
• Complies with Utilization Management and Case Management standards of practice.
• Performs other duties as assigned.

1. Education and/or Training:

• Associate’s degree in nursing required.
• Bachelor’s degree in nursing preferred.

2. Professional

Experience:

• Minimum two (2) years of prior experience in utilization management or case management is preferred.
• Knowledge of Medicare is required.
• Knowledge of Medicaid, HMO, and private insurance is preferred.
• Knowledge in accreditation standards (i.e., NCQA, URAC) is preferred.

3.

Licenses/Certifications:

• Current active, unrestricted state licensure as a Registered Nurse is required. [URAC.CC-HUM 10 (a)]
• Utilization Management or Case Management certification is preferred.

4. Specialized

Skills:

• Professional license must be with a scope of practice that will be relevant to initial clinical review. [URAC.CC-HUM 10 (b)]
• Strong clinical background and solid clinical judgement to conduct initial clinical review is required. [URAC.CC-HUM 10 (b)]
• Employ effective use of knowledge and critical thinking skills.
• Apply effective time and project management skills.
• Strong interpersonal skills.
• Performance management skills.

5. Technical

Skills:

• Strong PC skills; MS Word, Excel, Access, and Power Point.

6. Additional Considerations:

• Applicants must be able to pass a background investigation as all offers are pending a successful completion of background check per the company policy.

1. Physical

Activities:

• Some travel may be required.

2. Mental

Activities:

• General mental activity related to job duties.