Inpatient Utilization Management Specialist

Group Health Cooperative of Eau Claire; Altoona (WI); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Wellness walks

Health & Fitness challenges

On-site fitness classes

Sit/Stand stations

And more!

Job summary

Group Health Cooperative of Eau Claire in Altoona, WI is seeking an Inpatient Utilization Management Specialist (RN) to assess, plan, and conduct utilization reviews and discharge planning to optimize member health outcomes. The role requires collaboration with an interdisciplinary team, documentation of determinations, and adherence to policy, HIPAA, and state and accreditation requirements.

This full-time position offers a comprehensive benefits package, vacation, retirement plan, health and

Qualifications

• Must have customer service skills and strong communication abilities.
• Professionals must demonstrate attention to detail and the ability to work under pressure.
• Ability to collaborate with diverse teams and adapt to changing priorities.

Responsibilities

• Processes prior authorization and pre-certification requests using tools and resources to determine medical necessity and benefit coverage.
• Displays initiative in problem-solving, prioritizing tasks, and managing workload.
• Consults with Market Leader, CMO, as necessary and implements changes.
• Plans and implements strategies to reduce length of stay and ensure medically necessary admissions.

Skills

Customer service

Verbal communication

Written communication

Attention to detail

Teamwork

Education

RN license

Job description

Employment opportunities with the Cooperative.

Health is Our Business

Making a move with your employment is a big deal. If you're considering working at the Cooperative, you may be wondering what we are all about.

Member-Focused

We work hard each and every day to build genuine, meaningful relationships, answer questions and offer solutions to your members. We want them to know we are here every step of the way when it comes to health care.

Community-Driven

Our roots are firmly planted in western Wisconsin. We believe in being actively involved in the communities we serve. Employees are encouraged to participate alongside us through sponsorship events, community restoration projects, fundraising opportunities, and much more.

Voted one of the Best Employers in the Chippewa Valley three years in a row!

Great Culture with Amazing Benefits

As the saying goes, work hard...play harder. You should like the people you spend the day with and we do! We celebrate big and little things each year, because it's a truly important part of a healthy work culture.

WORK WITH US

Current Openings

Think you'd be a good fit? See what opportunities we have available below.

Location: Altoona, WI

Job Id:1539-1315

# of Openings:1

Position Purpose

With minimal supervision the Inpatient Utilization Management Specialist assesses, plans, directs, and conducts utilization reviews, discharge planning and transition of care to optimize health care outcomes for our members. Reviews are conducted using evidence-based clinical criteria to determine if admissions and services are medically necessary and a covered benefit under the members health plan. The UM Inpatient Specialist functions as part of an interdisciplinary team. Communicates and documents review determinations in accordance with established policy/procedures, applicable state, federal and accreditation requirements. Relates effectively with others both internally and externally for continuity of care; maintains satisfactory relations with others, maintains accurate and complete records

Essential Position Functions

• Processes prior authorization and pre-certification requests using tools and resources to determine whether the proposed services meet the clinical requirements for medical necessity, appropriate level of care, health plan benefit coverage, network status, and accuracy.
• Displays initiative and competence in problem-solving, prioritizing tasks, and managing overall workload.
• Consults and reviews with Market Leader, CMO, as necessary;
• Embraces change with a positive attitude;
• Plans and implements strategies to reduce length of stay and to ensure hospital admissions are medically necessary according to national guidelines;
• Advocates on behalf of the member regarding accessibility, type, and quality of services within the benefit structure to provide possible solutions to best meet the member’s needs;
• Works in collaboration with hospital staff and member to ensure discharge and transition of care needs of the member are met;
• Identify quality events through the utilization review process;
• Assists member with education needs and in understanding their discharge plan;
• Communicates effectively with co-workers as well as providers regarding continuity of care, including discharge planning;
• Attends professional workshops, seminars, and in-service training; transfers knowledge to co-workers;
• Participates in identifying process areas for improvement, possible solutions, and leads or assists in implementing changes;
• Maintains member confidentiality by following GHC standards, including HIPAA;
• Displays empathy and compassion while maintaining policy and benefit specifics;
• Works well independently and as part of a team. Is helpful, approachable, and team oriented. Maintains good rapport with colleagues, ancillary departments, members, and providers;
• Completes reviews with timeliness and accuracy of decision-making;
• Maintains a professional demeanor when accepting and prioritizing urgent requests.

Minimum Requirements of the Position

• Registered nurse (R.N.) with a valid license or experience or education. Experience conducting medical reviews within medical, behavioral health and/or long-term care environments is preferred;
• Must demonstrate high degree of customer service skills, including excellent verbal and written communication skills;
• Must be able to work under pressure with strong attention to detail;
• Ability to learn and adapt in a changing environment with changing priorities;
• Ability to work with and influence a diverse population.

Benefits

• Wellness Walks
• Health & Fitness Challenges
• On-Site Fitness Classes
• Sit/Stand Stations
• And More!

Group Health Cooperative of Eau Claire complies with applicable Federal civil rights laws and does not discriminate, exclude or treat candidates less favorably on the basis of race, color, national origin (including limited English proficiency and primary language), age, disability, or sex (including sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity; and sex stereotypes).

The Cooperative is committed to fostering a caring and compassionate environment while ensuring that individual differences are valued. The Cooperative is a quality driven cooperative built on collaboration, community involvement, innovation, and belonging. It is essential that all employees and members feel secure and welcome, that the opinions and contributions of all individuals are respected and that all voices are heard.

This full time position offers an outstanding benefit package, including three weeks of vacation the first year, a generous retirement plan, health and dental insurance, a wellness program, and much more!

Group Health Cooperative of Eau Claire is an affirmative action and equal opportunity employer.