Utilization Management Nurse

ArchWell Health, LLC; Nashville (TN); On-site; USD 90,000 - 115,000; Full time

Job summary

ArchWell Health, LLC is seeking an Utilization Management Nurse to ensure patients receive appropriate, cost-effective care by reviewing medical services, treatments, and procedures. Reporting to the Director of Utilization Management, you will assess medical records and treatment plans to support care decisions.

The role requires active RN licensure, 3 years in utilization management, and comfort with CMS guidelines. Travel up to 20% is expected to collaborate across markets and providers.

Qualifications

• AA/AS in nursing required; BSN preferred.
• Active RN license in state(s) of employment.
• Minimum 3 years in utilization management.
• Experience in acute care, community clinic or senior-focused settings preferred.
• Spanish or other language skills desirable but not required.

Responsibilities

• Conduct prospective, concurrent, and retrospective utilization reviews for medical necessity.
• Collaborate with providers and Medical Directors on approvals or determinations per CMS guidelines.
• Maintain accurate records of reviews and communications.
• Analyze utilization trends toward organizational goals.
• Educate providers and patients on appropriate levels of care and service criteria.
• Collaborate to identify opportunities to educate on value-based care and improve cost-effectiveness.

Skills

Utilization management

Data analysis

Medical records review

Evidence-based practice

Communication

Travel up to 20%

Spanish language (-desirable)

Education

RN license (state(s) of employment)

BSN preferred

AA/AS in Nursing

Job description

Overview

Reporting to the Director of Utilization Management, the Utilization Management Nurse is responsible for ensuring that patients receive appropriate, cost-effective care by reviewing and evaluating medical services, treatments, and procedures. This role identifies trends for opportunities to educate and collaborate with healthcare providers, patients, and specialists to optimize resource utilization and improve patient outcomes.

Duties/Responsibilities

• Conducts prospective, concurrent, and retrospective utilization reviews for medical necessity to ensure treatment and services are appropriate and necessary by reviewing medical records and treatment plans.
• Works collaboratively with healthcare providers and Medical Directors to provide guidance on approvals or requests for health plan determination reviews as applicable utilizing CMS clinical guidelines and insurance policies.
• Maintains accurate and detailed records of reviews, interventions, and communications to ensure adherence to health plan requirements and organizational policies.
• Analyze utilization trends to ensure progress towards organizational goals
• Educates healthcare providers and patients regarding appropriate levels of care and service criteria and guidelines.
• Collaborates with Network and specialists to identify opportunities to educate on value-based care, resolve specialty gaps by markets, improve cost-effectiveness and coordination of care to meet patient needs.

Required Skills/Abilities

• Strong knowledge of utilization management functions in value-based care, including data analysis, claims review, reimbursement practices, and medical records reviews.
• Thorough, in-depth knowledge of evidence-based practice, legal rules and regulations and best practices in healthcare
• Ability to effectively leverage business and organizational knowledge within and across functional areas
• Must possess a high degree of emotional intelligence and integrity, driven and focused work ethic
• Continuous desire to learn and embrace new methods; ability to adapt and be resilient.
• Self-starter with the ability to think creatively and work effectively
• Ability to build a relationship and work effectively with various seniorities and diverse populations.
• Excellent critical reasoning, decision-making, and problem-solving skills to make informed decisions and ensure effective resource utilization while maintaining quality patient care.
• Willingness and ability to travel, up to 20%

Education and Experience

• AA/AS degree in Nursing required; BA/BS degree in Nursing (BSN) or Healthcare Administration preferred
• A valid, active Registered Nurse (RN) license in state(s) of employment required
• A minimum of 3 years’, current direct utilization management required
• Work in an acute care facility, community-based clinic, public health department or specialization with the senior population preferred
• Fluency in Spanish or other languages spoken by people in the communities we serve is desirable, but not required

ArchWell Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to their race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected classification.