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Utilization Management Nurse

2 months ago

York, United States WellSpan Health Full time

Utilization Management Nurse (RN) - Pop Health - Day (Temporary)

Location: WellSpan Health, York, PA

Schedule: Full Time

Schedule and Location

Temporary Role thru January 2025

Full Time: 40 Hours/Week

Hours: Monday - Friday 8am - 4:30pm

This is a remote position where the ideal candidate would be located in South Central Pennsylvania or in Northern Maryland, but exceptional candidates located outside of the service area may be considered. Occasional travel required within WellSpan's geographic footprint.

General Summary

Performs a variety of reviews and applies utilization and case management techniques to determine the most efficient use of resources to support the provision of appropriate, cost effective and quality health care. Provides leadership in the integration of utilization management principles throughout the System. Responsible for screening patients for care management programs, including complex care management.

Duties and Responsibilities

Essential Functions:

  • Determines medical necessity, appropriateness of admission, continued stay and level of care using a combination of clinical information, clinical criteria, and third-party information. Refers cases for which criteria are not met to the Medical Director.

  • Demonstrates a working knowledge of managed care agreements based on available resources which may include UM Manual, policy and procedure, and facility contract information.

  • Identifies areas to improve the cost effectiveness of care while maintaining quality, such as, length of stay, medications, therapies, and diagnostic tests. Liaisons between case management team, third party payors and the treatment team regarding the identified treatment plan in accordance with contractual guidelines or System policy.

  • Serves as a liaison between the Medical Director, Physicians, and office staff in resolving authorization questions and issues.

  • Educates physicians and staff regarding appropriate level of care and utilization issues.

  • Assists the patient care team with the identification and coordination of alternative treatment settings which will provide appropriate care, maintain quality of care, and reduce cost.

  • Identifies conditions which require case management across the continuum. Collaborates with the members of the patient care team to identify interdisciplinary needs. Refer to appropriate care management or disease management program.

  • Assists with the collection and analysis of utilization patterns and denied cases.

Common Expectations:

  • Prepares and maintains appropriate documentation as required.

  • Maintains established policies and procedures, objectives, quality assessment and safety standards.

  • Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

  • Prepares and presents utilization data analysis as required.

  • Develops and initiates educational programs regarding utilization management principles.

  • Attends meetings as required.

Qualifications

Minimum Education:

  • Associates Degree Required

Work Experience:

  • 3 years Relevant experience. Required

  • Experience in utilization management, case management, or clinical nursing specialty. Preferred and

  • Working in Human Resources with specific responsibility for leave of absence administration or management. Preferred

Licenses:

  • Licensed Registered Nurse Upon Hire Required or

  • Registered Nurse Multi State License Upon Hire Required

Apply Now

You’re unique and you belong here.

At WellSpan Health, we are committed to treating all applicants fairly and equitably, regardless of their job classification. If you require assistance or accommodation due to a disability, please reach out to us via email atcareers@wellspan.org. We will evaluate requests for accommodation on a case-by-case basis. Please note that we will only respond to inquiries related to reasonable accommodation from this email address. Rest assured, all requests for assistance or accommodation are handled confidentially, allowing applicants to share their needs openly and honestly with us.

WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic.