Utilization Management Registered Nurse
2 weeks ago
The Role of Utilization Management RN involves overseeing the inpatient Utilization Management process, which includes both in-network and out-of-network services, case management, and discharge planning. This position serves as a liaison between the Independent Practice Association (IPA) and healthcare facilities to enhance collaboration and operational efficiency.
This role is primarily office-based and requires some travel within the designated area.
A one-time sign-on bonus is available for this position.
Key Responsibilities:
- Conduct concurrent reviews with precision.
- Identify and document levels of care accurately.
- Coordinate and document comprehensive discharge planning.
- Manage in-network services for out-of-network discharges.
- Ensure appropriate utilization of in-network specialists, providers, and facilities.
- Participate in daily inpatient readmission review rounds, presenting cases to medical directors and case managers.
- Facilitate transfers from out-of-network to in-network facilities.
- Collaborate with internal and hospital contract staff, including:
- Timely initiation of letters of agreement for out-of-network services.
- Providing insights for potential contracts.
- Identifying and communicating high-cost/high-risk cases.
- Overseeing utilization of contracted facilities and reporting on out-of-network usage.
- Build and maintain relationships with both network and out-of-network hospital staff.
- Work directly with hospitalists to develop and implement inpatient processes, including:
- Identifying patients for specialty clinic referrals.
- Ensuring timely communication between primary care providers and hospitalists.
- Providing direct case management activities as needed.
- Identifying patients for case management coordination.
- Facilitating referrals for specific health programs.
- Coordinating high-cost/high-risk patients for case management.
- Engage in various meetings and committees as assigned.
- Participate in inpatient Utilization Management and Quality Management projects, ensuring thorough and timely completion.
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