utilization management rn

UTILIZATION MANAGEMENT RN

There's no place like Liberty Health

Come explore career opportunities with
Liberty Health
, a dynamic leader in the healthcare industry. Join us

We are currently seeking an experienced:

UTILIZATION MANAGEMENT RN

JOB SUMMARY:

• Day-to-day management of Utilization Management queues, dashboards, members, ensuring all Utilization Management activities, which include authorization timeliness, discharge planning, adherence to policies and procedures to ensure high quality and cost-effective utilization management services.

• Ability to work decision letters timely and accurately

• Quality monitoring focusing on medical necessity guidelines and discharge planning opportunities to lower levels of care

• Assist the Director of Utilization Management with the Utilization Management Reports to be reviewed by Executive Leadership.

• Ability to contribute to the UM team to ensure compliant execution of UM program

• Review admissions and service requests for the following:

• Authorization requests to ensure appropriate care for members and within clinical guidelines

• Monitor members both inpatient/outpatient – provide updates to Director of Utilization Management and the clinical care teams

• Recommend more appropriate care if required

• Assess and coordinate discharge planning with Care Team.

• Assist co-workers with issues related to coding, medical records/documentation, pre-certification reimbursement and claim denials/appeals.

• Use critical thinking and problem-solving to navigate through the complexities of a member's health conditions while maintaining coverage within the program guidelines.

• Ability to focus on interventions for improvement

• Provides appropriate responses to providers regarding UM questions or direct these questions to the Director of Utilization Management

• Monitors utilization management queues and dashboards, assuring compliance with reporting and turnaround times.

• Participates in the interdisciplinary approach to support continuity of care

• Participates in the Case Management processes and assists with the development of case management programs

• Ability to participate and contribute with the written policies and procedures and workflows

• Ability to participate in the On-Call rotation to ensure timeliness is maintained

• Ability to work occasional after hours to ensure timeliness is maintained.

• Contribute to and attend UM meetings and UM huddles.

• Other duties as assigned

• Less than 10% travel to the corporate office for Department meetings

JOB REQUIREMENTS:

• Licensed Registered Nurse credentialed from an accredited school/college with 3–5 years of clinical experience

• Maintain Active Registered Nurse License, (Compact, RN preferred)

• 1–5 years managed care Utilization Management experience (preferably with a Health Plan)

• Demonstrated experience in health plan utilization management, initial reviews, facility concurrent review discharge planning, and case management required.

• Medicare Advantage experience required

• Experience with InterQual or MCG authorization criteria preferred.

• Excellent computer skills and the ability to learn new systems are required.

• Strong attention to detail, organizational skills, and interpersonal skills are required.

• Demonstrated ability to problem-solve and manage professional relationships.

• Healthcare industry knowledge

• Excellent listening, verbal, written and interpersonal communication skills.

• High level of professionalism and confidentiality, with a strong customer focus.

• Can adapt well to operational needs with excellent follow-up skills.

• Must be self-motivated, with a work ethic of dedication and the discipline to work independently.

• Must have a valid driver's license.

• Proven ability to communicate concisely and confidently with all staff levels. Clearly communicates instructions to remote users.

Visit for more information.

Background checks/drug-free workplace.

EOE.