Utilization Management & Complex Case Manager, Registered Nurse (FT, Remote)

Santa Barbara Cottage Hospital; United States; Remote; USD 75,000 - 90,000; Full time

Job summary

Join a leading healthcare organization as a Utilization Management & Complex Case Manager, where you'll ensure patients receive optimal care. This remote position requires an RN with clinical experience to manage authorization requests and comprehensive case management, contributing to effective patient outcomes.

Qualifications

• Current, unrestricted RN license with multi-state privileges.
• 3+ years nursing experience in a clinical setting.
• Experience performing utilization reviews.

Responsibilities

• Review authorization requests using evidence-based criteria.
• Conduct comprehensive assessments and develop care plans.
• Coordinate services across care transitions.

Skills

Technical proficiency

Clinical judgment

Communication

Education

Bachelor’s degree in nursing

Job description

Company Overview and Culture

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world's leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 55,000 employees spanning six continents. For more information, visit http://www.exlservice.com.

About EXL Health

We leverage Human Ingenuity and domain expertise to help clients improve outcomes, optimize revenue and maximize profitability across the healthcare ecosystem. Technology, data and analytics are at the heart of our solutions. We collaborate closely with clients to transform how care is delivered, managed and paid.

EXL Health combines deep domain expertise with analytic insights and technology-enabled services to transform how care is delivered, managed, and paid. Leveraging Human Ingenuity, we collaborate with our clients to solve complex problems and enhance their performance with nimble, scalable solutions. With data on more than 260 million lives, we work with hundreds of organizations across the healthcare ecosystem.

We help payers improve member care quality and network performance, manage population risk, and optimize revenue while decreasing administrative waste and reducing health claim expenditures. We help Pharmacy Benefit Managers (PBMs) manage member drug benefits and reduce drug spending while maintaining quality. We help provider organizations proactively manage risk, improve outcomes, and optimize network performance. We provide Life Sciences companies with enriched data, insights through advanced analytics and data visualization tools to get the right treatment to the right patient at the right time.

Utilization Management & Complex Case Manager, Registered Nurse

This is a remote, telephonic position in the United States.

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.
• Assesses services for beneficiaries to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
• Conducts authorization reviews to determine financial responsibility for the payer and its beneficiaries.
• Approve services or refer cases to internal stakeholders based on findings.
• Makes appropriate referrals to other clinical programs.
• Refers appropriate authorization requests to and collaborates 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.
• Analyzes clinical service requests from beneficiaries or providers against evidence based clinical guidelines.
• Processes requests within required timelines.
• Collaborates with multidisciplinary teams to promote the care model.
• Adheres 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. Identify and include key concerns, needs, and preferences of the beneficiary and family/caregiver.
• 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. Collaborate and communicate with the beneficiary, family, significant other(s), physician, and other health care providers to accomplish the goals on the care plan.
• 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. Revise and update the care plan as needed in collaboration with the beneficiary and the health care team.
• 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 is aligned to state of residence and time zone:

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:

• Current, unrestricted RN license in state of residence with multi-state privileges (an active compact state license)
• 3+ years of experience as a nurse in a clinical setting
• 2+ years’ experience performing the utilization review for a health plan or inpatient facility
• 1+ year of experience as a case manager for a health planor 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.
• Ability to obtain Security Clearance required. Current DOD Security Clearance preferred
• Must hold United States Citizenship status
• Secure, private home office work environment

Preferred

• Bachelor’s degree in nursing from an accredited college, university, or school of nursing
• 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, Utilization Management Certification (CPHM)
• Active, Certified Case Management Certification (CCM)
• Experience working remotely

EEO/Minorities/Females/Vets/Disabilities

To view our total rewards offered click here —> https://www.exlservice.com/us-careers-and-benefits
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 includebonuses, as well as a Paid Time Off policy, and many region specific benefits.

Please also note that the data shared through the job application will be stored and processed by EXL in accordance with the EXL Privacy Policy.

Application & Interview Impersonation Warning– Purposely impersonating another individual when applying and / or participating in an interview in order to obtain employment with EXL Service Holdings, Inc. (the “Company”) for yourself or for the other individual is a crime. We have implemented measures to deter and to uncover such unlawful conduct. If the Company identifies such fraudulent conduct, it will result in, as applicable, the application being rejected, an offer (if made) being rescinded, or termination of employment as well as possible legal action against the impersonator(s).

EXL may use artificial intelligence to create insights on how your candidate information matches the requirements of the job for which you applied. While AI may be used in the recruiting process, all final decisions in the recruiting and hiring process will be taken by the recruiting and hiring teams after considering a candidate’s full profile. As a candidate, you can choose to opt out of this artificial intelligence screening process. Your decision to opt out will not negatively impact your opportunity for employment with EXL.

Other details

• Pay TypeSalary
• Employment IndicatorRegular
• Min Hiring Rate$75,000.00
• Max Hiring Rate$90,000.00
• Telecommute %100
• Required EducationBachelor’s Degree