Utilization Management RN

Imagine360; United States; On-site; USD 75,000 - 105,000; Full time

Benefits offered by this job

Health plans

Premium disability & life insurance

PTO 20 days

Holidays 10

Tuition reimbursement

401k

Disability & life insurance

Professional development

Diversity & inclusion

Job summary

Imagine360 is seeking a Utilization Management, RN for a 100% remote role. The candidate will perform medical necessity reviews, document findings in CaseTrakker, and guide non-clinical staff on clinical data interpretation.

You will collaborate with physician advisors and participate in QA activities. The position requires an active RN license in an eNLC state and 1+ year in Utilization Management, with preference for CCM certification and a Bachelor's degree.

Qualifications

• Nursing degree from an accredited college or university with an active, current RN license (eNLC).
• 1+ year in Utilization Management or Case Management preferred.
• Experience in utilization review services preferred; CPT/ICD knowledge helpful.

Responsibilities

• Perform utilization reviews to determine medical necessity per guidelines.
• Document reviews accurately in CaseTrakker and other systems.
• Provide guidance to non-clinical staff on clinical data interpretation.
• Communicate with physicians and peer reviewers per policy.
• Educate members using approved resources and participate in QA reviews.
• Attend meetings, trainings, and other job-specific events.
• Maintain patient privacy and confidentiality in all processes.

Skills

HIPAA compliance

Policy interpretation

Written communication

Microsoft Office

Data interpretation

Education

Nursing degree

RN license (eNLC)

Bachelor's degree preferred

Tools

CaseTrakker

Office software

Database software

Internet software

Job description

Imagine360 is seeking a Utilization Management, RN to join the team!

Position Location:

100% remote

Responsibilities include but are not limited to:

• Perform all tasks in accordance with Department of Labor, HIPAA, ERISA and Care 360 department Policy and Procedures.
• Complete HIPAA and URAC training annually.
• Identify, collect, process and manage data to complete reviews for Medical Necessity per imagine 360 approved clinical guidelines.
• Accurate utilization and documentation in appropriate software including time slips in CaseTrakker to complete and document the review process per Care 360 Policy and Procedure.
• Provide oversight to non-clinical staff members regarding interpretation of clinical data.
• Consult with Care 360 Physician Advisor or peer reviewer per policy and procedures.
• Assess and review current treatment history to identify appropriate referrals to Case Management Program or other Care 360 Services.
• Communicates professionally and effectively as needed with members, physicians, other healthcare professionals, peers, Supervisor of UM to complete the utilization process per Care 360 Policy and Procedures.
• Utilize clinical knowledge, expertise and imagine 360 approved educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures and/or treatment.
• Attend scheduled and periodic meetings, training and other job specific events as required either by teleconference or onsite.
• Participate in the Quality Management program of the organization by completing the Quality Assurance review process and other procedures per policy and procedure.
• Work regular scheduled hours and be available for additional coverage outside of normal working hours as needed.
• Evaluating clinical data.
• Assessment and evaluation of the acquired clinical data to assess for appropriateness of treatment plan based upon imagine 360 clinical guidelines.
• Coordination of treatment plans, interventions and outcomes measurement.
• Rationale for the effects of medication and treatments.
• Provide patient education and educational resources.
• Accurately report:
• Administration of medication and treatments
• Client response
• Contact with other health care team members
• Respect the client's right to privacy by protecting confidential information.
• Promote and participate in education and counseling to a participant based on health needs.
• Clarify any treatment that is believed to be inaccurate, non-effacious, or contraindicated by consulting with appropriate practitioner.
• Other duties as assigned.

Required Experience/Education:

• Nursing Degree from an accredited college or university and an active, current, and unrestricted Registered Nurse License in eNLC compact state
• Bachelors degree preferred
• 1+ year in Utilization Management and/or Case Management experience
• Experience in utilization review services preferred.
• Experience and knowledge of CPT and ICD coding preferred.

Skills and Abilities:

• Ability to read and interpret documents such as HIPAA compliance, safety rules, operating and maintenance instructions, and policy and procedure manuals.
• Ability to write routine reports and correspondence.
• Ability to speak effectively to members and employees.
• Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages.
• Ability to apply concepts of basic mathematics and fundamental accounting principles.
• Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.
• Ability to deal with problems and exercise sound judgment involving several concrete variables in standardized situations.
• To perform this job successfully, an individual must have basic knowledge and skills using Microsoft Office Word, Internet software, and Database software.

License and Certifications:

• Current, active, and unrestricted compact Registered Nurse license. Must maintain CEU's as required by the State Board of Nursing. Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization.
• Current Certified Case Manager (CCM) Certificate preferred; if Certification is not current, employee must pursue and achieve CCM Certification within three years of employment.

What can Imagine360 offer you?

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives

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Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.