Utilization Management Nurse

Medical Associates Clinic; Dubuque (IA); On-site; USD 65,000 - 85,000; Full time

Job summary

A leading healthcare provider in Dubuque is seeking a Utilization Management Nurse to join their team. This full-time role involves reviewing patient requests, ensuring effective treatment approaches, and coordinating care plans. The position offers a flexible schedule with potential remote work options after training and a comprehensive benefits package.

Benefits

Single or Family Health Insurance

401k with immediate matching

Flexible Paid Time Off Program

Life and Disability Insurance

Qualifications

• Three to five years of related experience required.
• Experience in utilization management preferred.

Responsibilities

• Review requests for procedures and medications.
• Facilitate options and services for health needs.
• Document authorizations, denials, and cost savings.

Skills

Critical Thinking

Communication

Analytical Skills

Education

Valid RN nursing license

Job description

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Medical Associates is looking for a Utilization Management Nurse to join our Health Care Services team!

Schedule: Primary schedule will be Monday through Friday 8:00am to 5:00pm, 40 hours/week with flexibility. After training, there is opportunity for work from home if desired!

Location: Training is in-person at Medical Associates Health Plans, 1605 Associates Drive, Dubuque, IA 52002

Benefits Package Includes:

• Single or Family Health Insurance with discounted premium rates for wellness program participation.
• 401k with immediate matching (50% on the dollar up to 7% of pay + additional annual Profit Sharing)
• Flexible Paid Time Off Program (24 days off/year)
• Medical and Dependent Care Flex Spending Accounts
• Life insurance, Long Term Disability Coverage, Short Term Disability Coverage, Dental Insurance, etc.
  
  

What You Will Be Doing:

• Review requests from providers or members for approval of procedures, medications, durable medical and/or services prior to delivery of the service.
• Utilize established screening criteria to ensure patients get the correct treatment from the resources that are available at the most cost effective level to meet their needs.
• Facilitate options and services for meeting individuals’ health needs with the goal of decreasing fragmentation, duplication of care and enhancing quality, cost‑effective clinical outcomes.
• Review of hospital and skilled admissions to justify continued care is medically necessary per Health Plan established guidelines.
  
  

Essential Functions & Responsibilities:

• Conduct reviews inclusive of physician referrals, medication reviews, admissions, utilization review updates, investigating alternatives to hospitalization such as home health care and durable medical equipment, utilizing the assessment process by obtaining pertinent patient history and accurate vital data, anticipating patient and family needs, working with the Health Choice Claims and Membership Services to determine benefit eligibility, facilitating crisis intervention, sharing information with co‑workers and documenting accurately. Utilize established screening criteria to determine medical necessity of requested authorizations. Refer patients to case management nurse or health coach as appropriate.
• Facilitate out‑of‑plan referrals, out‑of‑area urgent and emergent care for enrollees and provider offices and provide necessary information to Medical Director on specified referrals. Communicate decision to enrollees, providers, and facilities per established policies.
• Work collaboratively with internal and external staff, in determining extent of benefits and coverage for services being coordinated. Document authorizations, denials, cost savings and other outcome measurements.
• Act as a resource for the enrollee, provider offices, and other MAHP departments. Perform retrospective review to determine coverage of hospitalizations, and outpatient services. Communicate with enrollees regarding the use of managed care systems and participate in answering enrollees and providers inquiries.
• Assist in preparations for external review/regulatory agencies.
• Complete all other assigned projects and duties.
  
  

Knowledge, Skills and Abilities:

Experience - Three years to five years of similar or related experience.

Education - Valid RN nursing license is required.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Wellness and Fitness Services, Hospitals and Health Care, and Medical Practices

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