Utilization Management Nurse

ArchWell Health; Nashville (TN); On-site; USD 85,000 - 115,000; Full time

Job summary

ArchWell Health in Nashville is seeking an Utilization Management Nurse to review and evaluate medical services, treatments, and procedures to ensure appropriate, cost-effective care. This role reports to the Director of Utilization Management and partners with providers to educate patients and optimize resource use.

You will analyze utilization trends, maintain records for CMS and health plan compliance, and collaborate with networks to improve care coordination across markets.

Qualifications

• AA/AS degree in Nursing is required.
• Active RN license in state of employment.
• Minimum 3 years in utilization management.
• Experience in acute care facility or senior populations preferred.
• Spanish or other languages desirable.

Responsibilities

• Conducts prospective, concurrent, and retrospective utilization reviews for medical necessity.
• Collaborates with healthcare providers and Medical Directors on approvals or determinations.
• Maintains detailed records to ensure adherence to health plan requirements.
• Analyze utilization trends to meet organizational goals.
• Educates providers and patients on appropriate levels of care and service criteria.
• Collaborates to improve value-based care and coordination of care to meet patient needs.

Skills

Utilization management

Data analysis

Medical records review

Education & collaboration

Spanish language desirable

Education

AA/AS Nursing

RN license

BSN preferred

Job description

Job Summary

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
• Proficient PC skills
• 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.