Utilization Management Nurse

Medical Associates; Dubuque (IA); Hybrid; USD 65,000 - 90,000; Full time

Benefits offered by this job

Health Insurance

401k with matching

PTO 24 days/year

FSA (Medical & Dependent Care)

Life and Disability Insurance

Job summary

Medical Associates is seeking an Utilization Management Nurse to join our Health Care Services team. The role involves reviewing requests for approvals, applying screening criteria to ensure appropriate and cost-effective care, and coordinating with the health plan to determine benefit eligibility.

Primary schedule is Monday–Friday, 8:00am–5:00pm, 40 hours/week with flexibility. Training is in-person in Dubuque, IA, with potential for work-from-home after training.

Qualifications

• Valid RN nursing license is required.
• Three to five years of similar or related experience.

Responsibilities

• Review provider or member requests for approvals of procedures, medications, or services.
• Apply established screening criteria to ensure appropriate, cost-effective care.
• Facilitate options to meet health needs while reducing duplication of care.
• Review hospital and skilled admissions to justify continued care per guidelines.
• Coordinate with claims and health plan staff to determine benefit eligibility.

Skills

Utilization management

RN license

Healthcare experience

Communication

Collaborative work

Education

Registered Nurse license

Job description

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:

1. 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.
2. 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.
3. 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.
4. 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.
5. Assist in preparations for external review/regulatory agencies.
6. Complete all other assigned projects and duties.

Knowledge, Skills and Abilities:

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

Valid RN nursing license is required.