RN Coordinator Utilization Management

Energy Job Search; Menasha (WI); Remote; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking an RN Coordinator for Utilization Management. This role involves reviewing authorization requests, ensuring medical necessity, and collaborating with various departments to enhance operational processes. With a focus on quality improvement and cost savings, the position requires a strong clinical background and the ability to educate members and providers on utilization management practices. This remote opportunity is ideal for a dedicated RN looking to make a significant impact in healthcare management while enjoying the flexibility of a home-based role.

Qualifications

• 4+ years of clinical healthcare experience as an RN required.
• Current RN licensure in Wisconsin is mandatory.

Responsibilities

• Review and process prior authorization requests for medical necessity.
• Collaborate with departments to develop operational processes.

Skills

Clinical Healthcare Experience

Utilization Management

Insurance Knowledge

Patient Education

Education

Associate Degree in Nursing

Bachelor of Science in Nursing

Job description

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The RN Coordinator Utilization Management reviews submitted authorization requests for medical necessity, appropriateness of cares, and benefit eligibility. This individual also reviews applicable guidelines regarding payment and coverage, and makes determinations for authorization/payment.

Job Responsibilities

1. Demonstrates commitment and behavior aligned with the philosophy, mission, values, and vision of Network Health.
2. Appropriately applies all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies.
3. Evaluates and processes prior authorization requests/referrals submitted from contracted and non-contracted providers.
4. Follows Network Health process, policies, and procedures in authorization review of all membership on a pre-service, concurrent, and post-service basis. This includes verifying eligibility and benefits, and documenting all utilization management communication.
5. Provides education regarding utilization management activities and processes to members, caregivers, providers, and their administrative staff.
6. Participates in Utilization Management auditing (e.g., inter-reviewer reliability and denial files).
7. Refers members with complex health problems to Network Health Case Management to reduce costs and improve quality of life, using a holistic approach.
8. Collaborates with other departments to develop operational processes.
9. Supports Utilization Management programs and goals through active participation.
10. Identifies candidates for Case Management intervention and determines appropriate care levels based on Utilization Management criteria.
11. Completes assessments and care plans, including medication needs, treatment plans, follow-ups, red flags, disease management, advance directives, life planning, and self-management support.
12. Evaluates cases for cost savings and quality improvement opportunities.
13. Performs other duties as assigned.

Job Requirements

• Bachelor of Science in Nursing preferred.
• Associate Degree in Nursing required.
• Minimum of four (4) years of clinical healthcare experience as an RN.
• Experience in insurance, managed care, and utilization management preferred.
• Current RN licensure in Wisconsin required.

Candidates must reside in Wisconsin. This position is remote with reliable internet required.

We are an Equal Opportunity Employer committed to diversity.

Additional Details

Seniority level: Mid-Senior level

Employment type: Full-time

Job function: Healthcare Provider

Industries: Staffing and Recruiting