Utilization Management Nurse

Do you want to work from HOME? Do you want to work for a progressive company that is a leader in their industry? Here is what we are looking for: A hard working, progressive RN with leadership qualities.
Summary of Job: Responsible for the collection of personal and clinical information on participating Plan members for the purposes of: Providing patient education services, Rendering initial determinations of medical appropriateness for communication to the health benefit plan, and identifying individuals whose health and/or expenses may be positively affected through application of Large Case Management.
Specifics:
Perform Clinical Assessments -
Obtain appropriate information from health care provider and in some instances the patient or family in order to determine whether medical indicators satisfy criteria for planned procedure, admission, continued stay or discharge plan.Interpret nationally recognized criteria to support recommendations for inpatient and outpatient services.Determine when the clinical information does not satisfy criteria or a criterion does not exist for a treatment/service and refer these cases.Identify individuals whose health and/or expenses may be positively affected through the application of Large Case Management (LCM)and refer these patient’s to LCM in a timely manner. Reporting & DocumentationDocument each call completely, accurately and promptly into the computer system.Collect demographic, provider and clinical information to initiate an authorization for medical services that require prior authorization.Generate complete and accurate transmittals within the specified time frames.Work collaboratively with other departments, ensuring that pertinent information is communicated to the appropriate parties.Copying, faxing, filing (as needed).Follow documented policies and procedures for the handling of confidential materials and/or patient specific information. Customer ServiceAnswer direct telephone calls related to medical services in order to determine if prior authorization is required for the requested services.Retrieve and acknowledge messages requesting medical services from voicemail/e-mail.Complete all medical necessity reviews and communicate outcomes to providers within the appropriate time frames.Advise provider of Plan requirement of SSO, if needed, and direct patient to obtain SSO, assisting the patient if necessary in obtaining names of qualified specialists. Patient/Provider Education
Explain the function and role of HealthCare Strategies to the caller and refer the caller to the claims payor and PPO as indicated via HCS standard disclaimer scripting.Provide educational materials and direct callers to community services when indicated.
Other Duties -
Maintain working knowledge of the various role functions within the HCS Care Counselor process.Attend in-service educational seminars.Attend conventions with manager’s approval.Provide coverage for professional colleagues.
REQUIREMENTS


QUALIFICATION REQUIREMENTS: Required:
Active, unrestricted RN License3+ years experience in hospital setting1+ years previous utilization management exper. Must live within 30 miles of our office to qualify to work from home.
Abilities/Skills:
Strong verbal and written communication skills.Problem-solving and decision-making skills.Ability to carry out detailed written or verbal instruction independently.Basic mathematical skills.Basic computer skills.Familiarity with general office equipment.
Preferred:
5+ years previous UM experience