Utilization Management Nurse
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Job Description
Utilization Management Nurse supporting IntusCare’s PACE healthcare technology ecosystem for vulnerable seniors. Reviewing admissions, authorizations, claims, transitions, and provider appeals for compliant, value-based care.
Responsibilities:
- Adhere to PACE program service authorization policies and ensure participant care and claims are reasonable, necessary, medically appropriate, and consistent with care plans and PCP coordination decisions
- Conduct concurrent reviews of hospital admissions, including observation and inpatient stays
- Drive timely transitions of care and retrospectively review inpatient admissions under 48 hours
- Review claims submitted inconsistently with service authorization
- Conduct concurrent reviews of subacute and SNF admissions and support discharge planning and transitions of care
- Coordinate and review services delivered by contracted providers for consistency with authorizations, care plans, and PCP decisions
- Use clinical knowledge, critical thinking, and analytical skills to advocate for quality care, improved quality of life, and reduced hospital stays when appropriate
- Maintain accurate records of patient-related interactions
- Lead the provider appeals process for rejected claims
- Review provider network appeals and collaborate with the PACE Medical Director to issue written determinations
Requirements:
- 3 to 5 years of utilization management experience
- Current RN license
- Proven experience working in risk-based integrated models of care
- Ability to use data to drive decisions and collaborate with internal and external stakeholders
- Strong strategic thinking, problem-solving, and decision-making skills
- Excellent communication and leadership abilities
- Position is based in the United States
- Must not require visa sponsorship
Benefits:
- Competitive salary and equity package
- Comprehensive health, dental, and vision insurance
- Collaborative, inclusive, and dynamic work environment
- Opportunities for professional growth and development
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