RN Utilization Review & Care Management Specialist

11000 Central Office; United States; On-site; USD 57,000 - 86,000; Full time

Job summary

Intermountain Health seeks an RN Utilization Review Care Management I to apply clinical expertise in utilization review, ensure appropriate medical necessity, and promote cost-effective, high-quality care. The role collaborates with patients, families, providers and insurers for compliant, efficient services.

Shifts cover enterprise wide in Peaks/Canyons/Desert regions with regular two days per week and occasional weekends; compact licensure required; strong communication and regulatory

Qualifications

• Current RN license in state of practice with compact licensure within service area.
• BSN from an accredited institution; degree verification required.
• RNs must obtain BSN within four years of hire/promotion.
• Experience in care management/navigation or related field including Utilization Management, discharge planning, managed care, health promotion, health coaching, behavioral health, or Patient Educator role.
• Clinical nursing experience in inpatient hospital setting; familiar with hospital terminology and processes.
• Understanding of disease management including treatment, LOS, barriers to care.

Responsibilities

• Reviews and investigates medical records; applies clinical expertise to determine appropriate utilization and medical necessity.
• Applies evidence-based guidelines and medical policies for prior authorization and post-service reviews.
• Adheres to regulatory guidelines and communicates with members and providers.
• Engages with providers to ensure safe, efficient care, appropriate setting, and transitions of care.
• Collaborates with physicians, staff, members, and families to expedite authorizations and direct toward medically necessary care.
• Engages with members/providers for continuity of care, redirection, and authorization determinations.
• Resolves queries regarding authorizations, treatment plans, and medical necessity.
• Mentors UM LPN and non-clinical staff on processes and resource application.

Skills

Utilization Management

Clinical Expertise

Investigative Acumen

Medical Diagnosis & Treatment

Medical Terminology

Time Management

Problem Solving

Quality Care

Communication

Team Collaboration

Education

BSN

RN License

Tools

Microsoft Office

Job description

Intermountain Health seeks an RN Utilization Review Care Management I to apply clinical expertise in utilization review, ensure appropriate medical necessity, and promote cost-effective, high-quality care. The role collaborates with patients, families, providers and insurers for compliant, efficient services.

Shifts cover enterprise wide in Peaks/Canyons/Desert regions with regular two days per week and occasional weekends; compact licensure required; strong communication and regulatory