Utilization Management Nurse Specialist

1 week ago


Lancaster, Pennsylvania, United States Jefferson Health Plans Full time
About the Role

We are seeking a skilled and detail-oriented Utilization Management Nurse to join our team at Jefferson Health Plans.

Key Responsibilities
  • Ensure cost-effective and quality utilization management in acute care settings for pediatric and adult populations.
  • Review clinical information from facilities and communicate UM determinations in a timely manner.
  • Perform concurrent review and admission review on hospital admissions using InterQual criteria guidelines.
  • Track assigned cases for timely reviews and updates, and make decisions as reflected in case documentation.
  • Collaborate with providers, members, and interdepartmentally to ensure effective utilization management.
Requirements
  • Licensed Registered Nurse with an active license to practice professional nursing in Pennsylvania.
  • 2 years of medical/surgical, utilization review, and emergency room experience.
  • BSN preferred.
  • Thorough understanding of managed care systems and utilization review criteria.
  • Recent experience in a hospital, insurance company, or independent review company in utilization, quality review, or case management.
What We Offer
  • Competitive compensation packages, including 401(k) savings plan with company match and profit sharing.
  • Flextime and work-at-home options.
  • Benefits and wellness program, including generous time off.
  • Opportunities for professional growth and development.


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