Utilization Mangement Nurse-Team Lead

Intus Care; United States; Remote; USD 85,000 - 90,000; Full time

Job summary

An established industry player is seeking a skilled Registered Nurse to join their innovative team in healthcare technology. This role focuses on utilization management, ensuring that participant care aligns with medical standards and needs. You will collaborate with interdisciplinary teams to streamline communication, enhance care coordination, and prevent unnecessary hospitalizations. The position offers a competitive salary and comprehensive benefits, along with opportunities for professional growth in a dynamic and inclusive work environment. If you are passionate about making an impact in healthcare and thrive in fast-paced settings, this opportunity is perfect for you.

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Professional Growth Opportunities

Collaborative Work Environment

Qualifications

• 3 to 5 years of utilization management experience required.
• Current RN license is mandatory.

Responsibilities

• Manage utilization processes to ensure proper service authorization.
• Coordinate claim disputes and mentor the UM team.

Skills

Utilization Management

Critical Thinking

Data Analysis

Communication Skills

Leadership Abilities

Problem Solving

Process Improvement

Education

Registered Nurse License

Job description

Intus Care is seeking an experienced Registered Nurse with utilization management experience. This position will support the Interdisciplinary Team and other stakeholders through robust data analysis to promote care coordination, prevent hospitalizations, and minimize unnecessary and/or unwanted participant care.

In addition, this position will work with Intus Care PACE Program customers to streamline communication with and between the PACE provider network, Medical Director, Interdisciplinary Team, and the finance team. Ensuring efficient service authorization and documentation of appropriate and high-quality services that are aligned with the participants' needs and goals of care. This position will be responsible for managing and overseeing communication processes and decision-making regarding participant service review and authorization, ensuring consistent and accurate documentation throughout the care cycle that supports appropriate payment of service claims.

What We Do

Intus Care is a healthcare analytics platform that synthesizes healthcare data to identify risks, visualize trends, and optimize care for PACE programs. Intus Care empowers care providers to mitigate high risk events and equips executives with the tools to make informed decisions based on comprehensive clinical and operational data. Our mission is to catalyze data driven change to achieve high-value, multi-disciplinary care for older adults. In addition, Intus Care offers a broad range of technical assistance and consulting services to support new PACE programs under development and existing programs that are growing and evolving to meet the needs of their communities.

Responsibilities

1. Assure rigorous adherence to PACE program service authorization policies, ensuring that participant care and related claims are:

   1. Reasonable and necessary for diagnosis or treatment and consistent with PCP coordination decisions.

   2. In accordance with accepted medical standards and consistent with the participant care needs including level of care and advanced care planning principles.

2. Actively participate in and/or manage various aspects of the utilization management process, including:

   1. Concurrent review of all hospital admissions (observation and inpatient) with the Interdisciplinary Team driving efficient and timely transitions of care, retrospective review of inpatient admissions under 48 hours, and claims submitted inconsistent with the service authorization.

   2. Concurrent review of all subacute and SNF admissions with the Interdisciplinary Team driving efficient and timely discharge plans and transitions of care.

   3. Coordination and review of all other services delivered by contracted providers and identified by the PACE program assuring consistency with Interdisciplinary Team service authorization, care plans, and PCP coordination decisions.

3. Coordinate Claim Disputes - In cases of claim rejection, the Intus Care Utilization Management Nurse will lead the provider dispute process. Responsibilities Include:

   1. Comprehensive review of provider network disputes.

   2. Collaboration with the PACE program finance and claims adjudication team to coordinate clinical review to support disputed claims as needed.

   3. Collaboration with the PACE Program's Medical Director to review and respond to disputes, ensuring issuance of a written determination consistent with the PACE program policies.

4. Mentorship of UM team.

Qualifications

• 3 to 5 years of utilization management experience.

• Current RN license.

• Proven experience working in risk based integrated models of care.

• Ability to use data to drive decisions and collaboration with internal and external stakeholders.

• Strong critical thinking skills and strong, autonomous self-management.

• Comfortable with rapid cycle improvement and thrives in fast paced performance improvement environments.

• Ability and willingness to identify and initiate process improvement strategies to implement and iterate on system changes.

• Strong strategic thinking, problem solving, and decision-making skills.

• Excellent communication and leadership abilities, capable of motivating and guiding teams toward timely and efficient care management strategies.

What We Offer

• A chance to be a part of a trailblazing team in healthcare technology.

• Competitive salary package.

• Comprehensive benefits including health, dental, and vision insurance.

• A collaborative, inclusive, and dynamic work environment.

• Opportunities for professional growth and development.

Company Core Values

• Take Ownership For Your Responsibilities and Outcomes.

• Think With Data First.

• Be Passionate About Impact.

• Take Strides Toward Growth and Innovation.

• Be Supportive Of Each Other.

Salary Range: $85,000-$90,000/year

Location: Remote.