Utilization Review RN - Case Coordination

Health Plans, Inc.; United States; On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

401(k) plan

Paid time off

Job summary

Health Plans, Inc. is seeking a UM Review Coordinator to review clinical information for medical necessity, determine appropriate level of care, and length of stay using standardized criteria.

The role includes gathering information, coordinating with Peer Reviewers, and managing utilization with timely documentation. The ideal candidate holds an RN license in MA/ME/NH or residency state, with at least three years in acute care and proficiency in Microsoft Office.

Qualifications

• A minimum of three years of experience in an acute care clinical setting.
• Active, current and unrestricted professional licensure as an RN in Massachusetts, Maine, New Hampshire or state of residency.
• Proficient in Microsoft Office, including Word, Excel, Outlook and PowerPoint

Responsibilities

• Gather relevant clinical information from appropriate health care providers.
• Confirm medical necessity for procedures based on standardized criteria; refer non-confirmable cases to Peer Reviewer.
• Conduct utilization management of appropriate level of care and length of stay.
• Consult with Peer Reviewers when peer input is needed.
• Provide timely case screening and referrals to Case Management or other programs.
• Ensure timely follow up on utilization management issues and inquiries.
• Collaborate with health care providers to identify discharge needs and facilitate timely discharge.
• Communicate with providers regarding the Utilization Management process.
• Ensure case documentation follows policy and procedures.
• Demonstrate ongoing professional growth with Manager guidance.
• Maintain quality audit scores and manage caseload efficiently.
• Adhere to HIPAA policies and procedures

Skills

Clinical review

RN licensure

Microsoft Office

Communication skills

Education

RN licensure (Massachusetts/Maine/New Hampshire)

Tools

Microsoft Office (Word, Excel, Outlook, PowerPoint)

Job description

Health Plans, Inc. is seeking a UM Review Coordinator to review clinical information for medical necessity, determine appropriate level of care, and length of stay using standardized criteria.

The role includes gathering information, coordinating with Peer Reviewers, and managing utilization with timely documentation. The ideal candidate holds an RN license in MA/ME/NH or residency state, with at least three years in acute care and proficiency in Microsoft Office.