Telephonic Utilization Management & Case Management Operations Registered Nurse | Remote

EXL Service; Minneapolis (MN); Remote; USD 60,000 - 95,000; Full time

Job summary

An established industry player is seeking a passionate Utilization Management & Complex Case Management Nurse to join their remote team. In this vital role, you will ensure patients receive the necessary care by reviewing authorization requests and providing comprehensive case management services. Your expertise will help beneficiaries regain optimal health through effective assessment, care planning, and collaboration with multidisciplinary teams. This position offers a unique opportunity to make a real difference in the lives of individuals with complex health needs, all while working in a supportive and innovative environment. If you are ready to take on a rewarding challenge that combines clinical knowledge with compassionate care, this role is perfect for you.

Benefits

Paid Time Off

Bonuses

Flexible Work Environment

Health Insurance

Retirement Plan

Qualifications

• Current RN license with multi-state privileges required.
• 3+ years clinical nursing experience and 2+ years in utilization review.

Responsibilities

• Review authorization requests using clinical judgment for medical necessity.
• Conduct comprehensive assessments and develop case management care plans.

Skills

Clinical Judgment

Communication Skills

Case Management

Utilization Review

Technical Proficiency in MS Office

Education

Bachelor's degree in nursing

Tools

MS Office Suite

Microsoft Teams

SharePoint

Job description

Telephonic Utilization Management & Case Management Operations Registered Nurse | Remote

Are you passionate about ensuring patients receive the care they need? Join our team as a Utilization Management & Complex Case Management Nurse, where you will play a crucial role in reviewing and approving authorization requests for appropriate care and provide comprehensive case management services for beneficiaries with multiple or complex conditions. You will follow established guidelines and policies, and when necessary, forward requests to the appropriate stakeholders. You'll also use your clinical knowledge, communication skills, and collaborative spirit to help our beneficiaries regain their optimum health or improve their functional capabilities. This involves performing comprehensive assessment, care planning, implementation, monitoring, and evaluation activities via telephonic contact and digital outreach.

Our team works diligently to ensure that beneficiaries progress toward desired outcomes with quality care that is medically appropriate and cost-effective. Our goal is to assist beneficiaries in regaining their optimal health or improved functional capability, support effective self-care management, and promote access to healthcare services and community resources.

Key Responsibilities:

• Review authorization requests using clinical judgment and evidenced-based clinical decision support criteria to ensure medical necessity and appropriate level of care.
• Assess services for beneficiaries to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Identify appropriate benefits and eligibility for requested treatments and/or procedures.
• Conduct authorization reviews to determine financial responsibility for the payer and its beneficiaries.
• Approve services or refer cases to internal stakeholders based on findings.
• Make appropriate referrals to other clinical programs.
• Refer appropriate authorization requests to and collaborate with Medical Directors.
• Educate providers on utilization and medical management processes.
• Enter and maintain clinical information in various medical management systems.
• Make evidenced-based independent decisions regarding work methods, even in ambiguous situations, with minimal direction.
• Analyze clinical service requests from beneficiaries or providers against evidence based clinical guidelines.
• Process requests within required timelines.
• Collaborate with multidisciplinary teams to promote the care model.
• Adhere to all UM policies and procedures, federal, state and regulatory guidelines.
• Conduct a comprehensive assessment with beneficiaries and analyze assessment findings to identify and prioritize clinical, psychosocial, and behavioral concerns and potential gaps in care.
• Develop and document a case management care plan in direct collaboration with the beneficiary, the beneficiary's family or significant other(s), the primary physician and other health care providers.
• Document identified issues, prioritized and individualized goals (long & short term), evidence-based interventions, collaborative approaches and resources, anticipated time frames, and barriers to achieving goals in the care plan.
• Coordinate and implement the activities specified in the care plan to provide optimal benefits coverage as well as promote continuity of care and integration of services for the beneficiary across care transitions.
• Monitor and continually evaluate the care plan on a scheduled basis to ensure it remains effective and to determine if desired outcomes are met and the goals are achieved.
• Collaborate with beneficiaries and their support system/caregivers, providers, the multi-disciplinary team, and health care and community resources throughout the case management process.
• Be familiar with and understand the scope of professional licensure and carry out case management activities consistent with the scope of this licensure.

Work Schedule

Monday - Friday 5 days x 8 hours

Shift Time for Remote Telephonic Work

• Pacific Time Zone 9 am - 6 pm PT
• Mountain Time Zone 10 am - 7 pm MT
• Central Time Zone 11 am - 8 pm CT
• Eastern Time Zone 11 am - 8 pm ET

Qualifications

Required

• Current, unrestricted RN license in state of residence with multi-state privileges (an active compact state license), or the ability to obtain multi-state privileges in the state of residence.
• 3+ years of experience as a nurse in a clinical setting.
• 2+ years’ experience performing utilization review for a health plan or inpatient facility.
• 1+ year of experience as a case manager for a health plan or inpatient facility.
• Strong technical proficiency with MS Office Suite Word, Excel, Power Point, Microsoft Teams and SharePoint and ability to navigate multiple systems under periods of high volume.
• Must hold United States Citizenship status.
• Ability to obtain Federal Security Clearance required. Current DOD Security Clearance preferred.
• Secure, private home office work environment.

Preferred

• Bachelor’s degree in nursing from an accredited college, university, or school of nursing.
• Experience working in a NCQA and URAC accredited program.
• Previous experience in Hospital Acute Care, Prior Auth, Utilization Review / Utilization Management and knowledge of InterQual and/or MCG guidelines.
• Health Plan experience working with large carriers. Previous Federal government plan program experience such as Tricare, Medicare Medicaid and commercial health insurance experience.
• Active, Certified Case Management Certification (CCM).
• Experience working remotely.

EEO/Minorities/Females/Vets/Disabilities

Base Salary Range Disclaimer: The base salary range represents the low and high end of the EXL base salary range for this position. Actual salaries will vary depending on factors including but not limited to: location and experience. The base salary range listed is just one component of EXL's total compensation package for employees. Other rewards may include bonuses, as well as a Paid Time Off policy, and many region-specific benefits.