Utilization Management RN: Care Optimization & Reviews

Peak Health; Core (WV); Vor Ort; USD 70.000 - 90.000; Vollzeit

Zusammenfassung

PHH Peak Health Holdings in the United States seeks a skilled Registered Nurse to support care management and utilization review programs. You will build and implement review processes, collaborate with Medical Directors, and educate stakeholders to improve patient outcomes and network services.

The role requires a nursing license, 3 years of clinical experience, and experience with Medicare/Medicaid management.

Qualifikationen

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
• Three (3) years of healthcare clinical experience.
• Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); Currently enrolled in a BSN program and BSN completion within three (3) years of hire.
• Medical Management for Medicare and/or Medicaid populations.
• Utilization Management experience.

Aufgaben

• Assists with the build and implements care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards.
• Assists with the build and implements all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies.
• Ensures that interventions are collaborative and focus on maximizing the member’s health care outcomes.
• Understands the Peer-to-Peer Review process and works with the Medical Directors to continuously improve member and Provider Network services for this process.
• Educates internal and external stakeholders and partners to continuously improve processes and build network relationships.
• Works collaboratively with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.
• Understands the data that is collected within the position, and work with other team members on improving outcomes.
• Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.

Kenntnisse

InterQual/Milliman Care Guidelines

Written and verbal communication

Problem solving

Microsoft Office

Ausbildung

RN license (state or eNLC)

BSN or ASN; BSN completion within 3 years

Jobbeschreibung

PHH Peak Health Holdings in the United States seeks a skilled Registered Nurse to support care management and utilization review programs. You will build and implement review processes, collaborate with Medical Directors, and educate stakeholders to improve patient outcomes and network services.

The role requires a nursing license, 3 years of clinical experience, and experience with Medicare/Medicaid management.