Utilization Management Registered Nurse

2 weeks ago

Oceanside, California, United States Neighborhood Healthcare Full time
Job Overview

At Neighborhood Healthcare, we are dedicated to fostering a community where health and happiness thrive. Our commitment to community health extends beyond basic medical services; we empower individuals with the resources necessary for a fulfilling life. As a private, non-profit 501(C)(3) organization, we proudly provide over 500,000 medical, dental, and behavioral health visits annually, serving more than 96,000 individuals. Our mission is to enhance the well-being of the communities we serve by delivering quality care to all, irrespective of their circumstances.

ROLE SUMMARY

The Registered Nurse specializing in Utilization Management plays a crucial role in facilitating communication among the PACE provider network, Medical Director, Interdisciplinary Team, and Finance Team. This position is essential for ensuring that service authorizations and documentation align with the needs and care objectives of participants. The nurse will oversee communication processes and decision-making regarding service reviews and authorizations, maintaining consistent and accurate documentation throughout the care continuum to support appropriate payment of service claims.

KEY RESPONSIBILITIES

  • Ensure adherence to PACE program service authorization policies, confirming that participant care and related claims are reasonable and necessary for diagnosis or treatment, in line with primary care provider (PCP) coordination decisions.
  • Monitor participant care and related claims to ensure compliance with accepted medical standards and alignment with participant care needs, including level of care and advanced care planning principles.
  • Engage in various aspects of the utilization management process, including:
    • Conducting concurrent reviews of hospital admissions with the Interdisciplinary Team to facilitate efficient transitions of care, retrospective reviews of inpatient admissions under 48 hours, and claims submitted inconsistent with service authorization.
    • Performing concurrent reviews of subacute and skilled nursing facility (SNF) admissions with the Interdisciplinary Team to promote timely discharge plans and transitions of care.
    • Coordinating and reviewing services provided by contracted providers to ensure consistency with Interdisciplinary Team service authorizations, care plans, and PCP coordination decisions.
  • Lead the provider appeal process for denied claims, including comprehensive reviews of provider network appeals and collaboration with the PACE Medical Director to review and respond to appeal requests, ensuring issuance of written determinations consistent with program policies.

EDUCATION AND EXPERIENCE

  • Bachelor's degree in nursing is required.
  • A valid CA Registered Nurse License is required.
  • Current BLS certification from an approved American Health Association provider is required upon hire.
  • A minimum of four years of registered nurse experience is required.
  • Two years of experience in utilization management is preferred.
  • Experience in risk-based integrated models of care is preferred.

ADDITIONAL QUALIFICATIONS

  • Exceptional verbal and written communication skills, including strong composition, typing, and proofreading abilities.
  • Ability to interpret a variety of instructions in written, oral, diagram, or schedule form.
  • Proficient in using data to inform decisions and collaborate with internal and external stakeholders.
  • Strong strategic thinking, problem-solving, and decision-making skills.
  • Leadership skills to motivate and guide teams toward effective care management strategies.
  • Ability to manage multiple tasks simultaneously.
  • Excellent planning and organizational skills.
  • Capacity to work collaboratively within a team as well as independently.
  • Ability to handle highly confidential information in a professional and ethical manner.

PHYSICAL REQUIREMENTS

  • Ability to lift and carry up to 10 lbs.
  • Ability to stand for extended periods.

Neighborhood Healthcare offers a comprehensive benefits package, including partially company-paid medical, dental, and vision plans, generous vacation time, holidays, sick/personal time, Volunteer Time Off (VTO), a 403b retirement plan, optional health and wellness events, and more.

Compensation: $62.75 per hour, based on experience.

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