RN Coordinator Utilization Management

Network Health WI; Menasha (WI); Hybrid; USD 60,000 - 80,000; Full time

Job summary

Network Health WI is seeking an RN Coordinator for Utilization Management to evaluate authorization requests for medical necessity and appropriateness of care. This role allows for home office work but requires occasional travel to the corporate office in Menasha for training and other purposes.

Ideal candidates will have at least an Associate Degree in Nursing and four years of experience in healthcare. This position includes responsibilities like reviewing guidelines for payments and providing education regarding processes.

Qualifications

• Bachelor of Science in Nursing preferred.
• Associate Degree in Nursing required.
• Current registered nurse licensure in Wisconsin required.
• Minimum 4 years clinical experience as a Registered Nurse.

Responsibilities

• Evaluate and process prior authorization requests from providers.
• Document utilization management communication accurately.
• Educate members and providers on usage management processes.
• Collaborate with departments to enhance operational processes.
• Identify candidates for Case Management intervention.

Skills

Clinical health care experience

Utilization management

Insurance knowledge

Education provision

Education

Bachelor of Science in Nursing

Associate Degree in Nursing

Job description

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

Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work from your home office (reliable internet is required). Travel to the corporate office in Menasha is required occasionally for the position, including on the first day. Training is required in person at our Menasha location for the first 6–8 weeks.

Hours: 1.0 FTE, 40 hours per week, 8 a.m. – 5 p.m. Monday through Friday

Job Responsibilities

• Evaluate and process prior authorization requests/referrals submitted from contracted and non-contracted providers.
• Follow Network Health process, policies, and procedures in authorization review of all membership on a pre-service, concurrent and post-service basis. This process includes verifying eligibility and benefits and documenting all utilization management communication.
• Provide education regarding utilization management activities and processes to members, caregivers, providers, and their administrative staff.
• Participate in Utilization Management auditing (i.e., Utilization Management Inter-reviewer reliability and denial files).
• Refer all members with complex health problems and needs to Network Health Case Management to reduce medical costs while providing a higher quality of life and an ability to take charge of their diseases. This requires an extensive holistic approach to care management assessment.
• Collaborate with other NH departments to develop interdepartmental operational processes.
• Support Utilization Management department programs and goals through active participation.
• Identify and screen candidates for Case Management intervention and determine appropriate level of care from Utilization Management criteria.
• Complete assessments and plans of care including need for medication regime, treatment plans, practitioner follow-up appointments, knowledge of red flags, disease management, Advance Directives, life planning, and self-management of illness to the best of member ability.
• Evaluate cases for cost savings/quality improvement potential.
• Other duties and responsibilities as assigned.

Job Requirements

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

Network Health is an Equal Opportunity Employer.