Utilization Management Nurse Specialist

7 days ago

Lancaster, Pennsylvania, United States Jefferson Health Plans Full time
Why Choose Jefferson Health Plans?

We are an award-winning, not-for-profit health maintenance organization offering Medicaid, Medicare, and Children's Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.

While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.

Perks of JHP and why you will love it here:
  • Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing
  • Flextime and Work-at-Home Options
  • Benefits & Wellness Program including generous Time Off
  • Impact on the communities we service

We are seeking a talented and enthusiastic Utilization Management Nurse to join our team

The Utilization Management Nurse is responsible for ensuring cost-effective, quality utilization management in the acute level of care setting for the pediatric or adult population in the post-acute inpatient setting (i.e., SNF/Rehab). Also, responsible to review clinical information provided by facilities and communicates UM determinations maintaining timeliness.

As the Utilization Management Nurse, your daily duties may include:

  • Review and track emergency admissions to identify appropriate level of care for acute and post-acute inpatient services.
  • Perform concurrent review and/or admission review on all hospital admissions using InterQual criteria guidelines.
  • Track assigned cases for timely reviews/updates and decisions as reflected in case documentation.
  • Request and review medical records to identify appropriate acute care days and approve or refer questionable days to the medical director for decision.
  • Function as a liaison between providers, members and interdepartmentally.
  • Serve as resource for physicians, PCPs, Utilization Review departments and all medical providers.
  • Identify trends that impact on utilization at hospitals during the review process and help resolve them.
  • Maintain departmental and regulatory timeframes for utilization decisions.
  • Contributes to the development and enhancement of documentation, tracking tools and process flows
  • Maintains collaborative and effective cross-functional training within the Utilization Management Department Utilization management perform after hour's on-call coverage.
  • Participates in relevant work groups and provide deliverables as necessary
  • Successful and timely completion of assignments in accordance with departmental and Company operational objectives and seeks feedback on performance. Ensures that assignments are scheduled and completed in an accurate and timely manner.
  • Maintains detailed knowledge of the status of all assignments and routinely updates the manager, as appropriate
  • Responsible to for after hour on call shifts as needed
  • Performs all other duties as assigned
Qualifications
  • Licensed Registered Nurse, must have an active license to practice professional nursing in the Commonwealth of Pennsylvania
  • 2 years medical/surgical, utilization review and emergency room experience.
  • BSN preferred.
Skills, We Value:
  • Must present polished professional image.
  • 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
  • Knowledge of health insurance including Medicare, Medicaid and managed care
  • Ability to work and communicate effectively with co-workers, members and providers at the owner institutions.
  • Must be organized, detailed oriented, and capable of handling multiple issues.
  • Excellent telephone and verbal/written communication skills.
  • Proficient use of Microsoft Office suite (Word, PowerPoint, Excel) required.

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