RN Coordinator Utilization Management

Network Health; Menasha, Midway Place (WI, LA); Remote; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a dedicated RN Coordinator for Utilization Management. This role involves reviewing authorization requests, ensuring compliance with guidelines, and collaborating with various departments to enhance operational efficiency. The ideal candidate will have a strong clinical background and a passion for improving patient care through effective utilization management practices. With the option for remote work, this position offers flexibility while contributing to a vital aspect of healthcare services. Join a diverse and inclusive team committed to making a difference in the lives of members.

Qualifications

• Minimum of four years clinical health care experience as a Registered Nurse.
• Current registered nurse licensure in Wisconsin required.

Responsibilities

• Reviews authorization requests for medical necessity and appropriateness of care.
• Collaborates with departments to develop operational processes.
• Provides education regarding utilization management to members and caregivers.

Skills

Clinical Health Care Experience

Utilization Management

Insurance Knowledge

Communication Skills

Education

Bachelor of Science in Nursing

Associate Degree in Nursing

Job description

Description

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:

• Demonstrates commitment and behavior aligned with the philosophy, mission, values, and vision of Network Health
• Appropriately applies all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies
• Evaluates and processes prior authorization requests/referrals submitted from contracted and non-contracted providers
• 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, as well as documenting all utilization management communication
• Provides education regarding utilization management activities and processes to members, caregivers, providers, and their administrative staff
• Participates in Utilization Management auditing (e.g., inter-reviewer reliability and denial files)
• Refers members with complex health problems and needs to Network Health Case Management to reduce costs and improve quality of life, using an extensive holistic approach to care management assessment
• Collaborates with other NH departments to develop interdepartmental operational processes
• Supports Utilization Management programs and goals through active participation
• Identifies and screens candidates for Case Management intervention and determines appropriate level of care based on Utilization Management criteria
• Completes assessments and care plans, including medication needs, treatment plans, follow-up appointments, red flags, disease management, Advance Directives, life planning, and self-management education
• Evaluates cases for cost savings and quality improvement potential
• Performs other duties as assigned

Job Requirements:

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

Candidates must reside in Wisconsin. This position is eligible for remote work with reliable internet.

We are proud to be an Equal Opportunity Employer who values and maintains a diverse workforce.