Utilization Management Nurse, PRN

Duly Health and Care; Downers Grove (IL); Remote; USD 70,000 - 95,000; Full time

Job summary

Join a leading healthcare provider as a Utilization Management Nurse, PRN, responsible for evaluating and ensuring appropriateness of patient care. This role offers remote work possibilities combined with on-site monthly training at the Corporate Office. The qualified candidate will have a nursing degree and experience in Utilization Review, assisting in effective patient discharge and care coordination.

Qualifications

• 2+ years of bedside hospital nursing experience.
• At least two years of concurrent Utilization Review experience.
• Case Management certification (CCM or ACM) is a plus.

Responsibilities

• Reviews inpatient and outpatient healthcare cases for medical necessity.
• Assesses patients for discharge planning and authorization of services.
• Collaborates with medical staff and investigates quality of care issues.

Skills

Knowledge of Milliman Care Guidelines

Experience in pre-certification

Familiarity with EPIC or other EMRs

Education

Associate, Diploma, or Baccalaureate degree in nursing

Job description

Join to apply for the Utilization Management Nurse, PRN role at Duly Health and Care

Overview

PRN

Hours - Day/Afternoon/Weekends; Must be willing to work 2-3 days per week and assist in covering vacations during winter/summer break.

Remote, with opportunity to come into the Corporate Office (Downers Grove) for monthly meetings and training.

The Utilization Management Nurse is responsible for reviewing inpatient, skilled nursing facility, acute rehab, long-term acute care, and home health cases to ensure criteria are met, length of stay is appropriate, and discharge needs are in place, while complying with regulatory requirements.

Responsibilities

• Performs initial and concurrent review on various healthcare cases, determining medical necessity based on established guidelines and regulations. Recommends care level adjustments as needed.
• Refers cases not meeting criteria to the Medical Director, communicates determinations, and suggests alternative services when appropriate.
• Assesses patients and families to assist in discharge planning, providing authorization for needed services, and monitoring outcomes.
• Identifies members with ongoing case management needs for referral to the Case Management team.
• Collaborates with medical staff to resolve patient care and physician issues.
• Investigates and reports quality of care issues as per policy.
• Supports Quality Assurance initiatives and reports problems for corrective action.
• Serves as an on-call nurse as per schedule.
• Prepares for and participates in health plan audits.
• Analyzes client data and runs reports as needed.
• Acts as a resource for staff, providers, patients, and families, assessing needs and developing action plans.
• Participates in departmental committees and special projects.
• Attends Utilization Management meetings and discusses cases affecting length of stay.
• Maintains current healthcare knowledge and confidentiality.
• Demonstrates alignment with company values and teamwork.
• Performs other duties as assigned.

Qualifications

• Knowledge of Milliman Care Guidelines or similar criteria; experience in pre-certification with capitated health plans preferred. Familiarity with EPIC or other EMRs is a plus.

Education and Certification

• Associate, Diploma, or Baccalaureate degree in nursing, with 2+ years of bedside hospital nursing experience.

Experience

• At least two years of concurrent Utilization Review experience in a health plan or hospital setting, with HMO and Medicare Advantage populations. Case Management certification (CCM or ACM) is a plus.