Utilization Management RN Nurse - Remote

Conifer Health Solutions; Frisco (TX); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare solutions provider is seeking a Utilization Management RN Nurse to ensure quality patient care and effective utilization of services. The role involves timely referral determinations, compliance with standards, and collaboration with healthcare providers. Ideal candidates will have RN licensure, managed care experience, and a strong understanding of medical coding.

Qualifications

• 3-5 years acute care experience; 2 years in health plan utilization review.
• RN licensure current and unrestricted.

Responsibilities

• Provide timely referral determinations using Milliman Care Guidelines.
• Collaborate with supervisors to address compliance issues.
• Work with providers and Medical Directors to facilitate quality service.

Skills

Managed Care

ICD-9 Coding

CPT Coding

Microsoft Office

Medical Terminology

Education

RN

BA in Nursing

BS in Nursing

Tools

EZ-CAP

Job description

Join to apply for the Utilization Management RN Nurse - Remote role at Conifer Health Solutions.

The purpose of the Utilization Management Nurse is to ensure quality of patient care, effective utilization of available health services, review of admissions for medical necessity and necessity of continued stay in the inpatient setting. Ensures members have a safe discharge plan in place prior to discharge from the inpatient setting.

Essential Duties And Responsibilities

• Provide timely referral determinations using Milliman Care Guidelines.
• Identify referrals for medical director review.
• Use appropriate letter language and coding for denials, deferrals, and modifications.
• Select preferred and contracted providers appropriately.
• Identify eligibility and benefits correctly.
• Code properly to route records or send determination notices.
• Maintain compliance with turnaround time standards.
• Collaborate with supervisors to address issues affecting compliance.
• Meet or exceed production and quality metrics.
• Work with providers and Medical Directors to facilitate quality service.
• Refer members to appropriate healthcare programs.
• Attend mandatory meetings and training.
• Maintain confidentiality of all files and documents.
• Collaborate with various departments to ensure consistent processes.
• Perform other duties as delegated.

Knowledge, Skills, Abilities

• At least 2 years managed care experience in UM/CM preferred.
• Knowledge of CMS, State Regulations, URAC, NCQA guidelines preferred.
• ICD-9 and CPT coding experience a plus.
• Proficient in Microsoft Office and health plan documentation systems.
• Experience with EZ-CAP and medical terminology preferred.

Qualifications

• RN licensure current and unrestricted.
• Minimum education: RN; preferred: BA or BS in Nursing.
• 3-5 years acute care experience; 2 years in health plan utilization review.

Physical Demands

• Sitting, computer use, and telephone work.
• Ability to travel and walk through hospital environments.

Work Environment

• Office setting.

Travel

• Approximately 5% travel required.