Utilization Management Nurse (RN) - Case Management - Day (Temporar

Energy Job Search; York (York County); Remote; USD 60,000 - 90,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated Utilization Management Nurse to provide exceptional case management and utilization oversight. This temporary full-time role offers the opportunity to make a significant impact on patient care while ensuring efficient resource use. As part of a collaborative team, you will determine medical necessity, educate staff, and enhance cost-effectiveness in care delivery. If you're passionate about improving healthcare quality and possess strong clinical expertise, this role is perfect for you.

Qualifications

• 3 years of relevant experience in utilization or case management.
• Licensed Registered Nurse required upon hire.

Responsibilities

• Determines medical necessity and appropriateness of admissions.
• Acts as a liaison between case management and treatment teams.
• Educates staff on utilization issues and care levels.

Skills

Utilization Management

Case Management

Clinical Nursing

Customer Service

Education

Associates Degree

Job description

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Job Description

Schedule

• Temporary Role (approximately 6 months)
• Full Time: 40 Hours/Week
• Hours: Monday - Friday 8am - 4:30pm
• Weekend Rotation Required

This is a remote position that requires candidates to be located within 50 miles of WellSpan's geographic footprint in South Central Pennsylvania or in Northern Maryland. Occasional travel is required within WellSpan's geographic footprint.

General Summary

Performs a variety of reviews and applies utilization and case management techniques to determine the most efficient use of resources to support the provision of appropriate, cost-effective, and quality health care. Provides leadership in the integration of utilization management principles throughout the System. Responsible for screening patients for care management programs, including complex care management.

Responsibilities

Duties and Responsibilities

Essential Functions

• Determines medical necessity, appropriateness of admission, continued stay, and level of care using clinical information, criteria, and third-party data. Refers cases not meeting criteria to the Medical Director.
• Demonstrates knowledge of managed care agreements based on available resources, including UM Manual, policies, procedures, and facility contracts.
• Identifies ways to improve cost-effectiveness of care while maintaining quality, such as length of stay, medications, therapies, and diagnostics. Acts as liaison between case management team, payors, and treatment team regarding treatment plans.
• Serves as a liaison between Medical Director, Physicians, and staff to resolve authorization issues.
• Educates physicians and staff on appropriate care levels and utilization issues.
• Assists care teams in identifying and coordinating alternative treatment settings to ensure appropriate, quality, and cost-effective care.
• Identifies cases requiring case management across the continuum. Collaborates with care team members to meet interdisciplinary needs. Refers to appropriate care or disease management programs.
• Assists in collecting and analyzing utilization patterns and denied cases.

Common Expectations

• Prepares and maintains required documentation.
• Follows policies, objectives, quality standards, and safety protocols.
• Provides excellent customer service, fosters teamwork, and practices fiscal responsibility.
• Prepares and presents utilization data analyses as needed.
• Develops educational programs on utilization management principles.
• Attends meetings as required.

Qualifications

Minimum Education

• Associates Degree Required

Work Experience

• 3 years relevant experience required
• Experience in utilization or case management, or clinical nursing preferred
• Experience in Human Resources with leave of absence management preferred

Licenses

• Licensed Registered Nurse upon hire required or
• Registered Nurse Multi-State License upon hire required

About Us

WellSpan Health aims to reimagine healthcare through comprehensive, equitable health and wellness solutions. As an integrated system, we have over 2,300 providers, 250 locations, nine hospitals, and serve central Pennsylvania and northern Maryland, focusing on value-based care and high-quality services.