RN Coordinator Utilization Management

Network Health; Brookfield (WI, IL); Remote; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a dedicated RN Coordinator for Utilization Management. In this pivotal role, you will review authorization requests, ensuring medical necessity and benefit eligibility while collaborating with various departments to enhance operational processes. This position offers the flexibility of remote work, allowing you to balance your professional responsibilities with personal commitments. If you have a passion for patient care, a strong clinical background, and the ability to navigate complex healthcare systems, this opportunity is perfect for you. Join a team that values diversity and inclusion in a supportive environment.

Qualifications

• 4+ years of clinical experience as a Registered Nurse (RN).
• Current registered nurse licensure in Wisconsin required.

Responsibilities

• Evaluates and processes prior authorization requests from providers.
• Collaborates with departments to develop operational processes.
• Completes assessments and care plans for patients.

Skills

Clinical Healthcare Experience

Utilization Management

Patient Education

Interdepartmental Collaboration

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, including verifying eligibility and benefits and 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 file reviews)
• Refers members with complex health issues to Network Health Case Management for comprehensive care management
• Collaborates with other departments to develop interdepartmental operational processes
• Supports Utilization Management programs and goals through active participation
• Identifies candidates for Case Management intervention and determines appropriate care levels based on Utilization Management criteria
• Completes assessments and care plans, including medication needs, treatment plans, follow-up appointments, red flags, disease management, advance directives, and self-management education
• Evaluates cases for cost savings and quality improvement opportunities
• Performs other duties as assigned

Job Requirements:

• Bachelor of Science in Nursing preferred; Associate Degree in Nursing required
• Minimum of four (4) years clinical healthcare 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 that values diversity and maintains an inclusive environment.