Utilization Management Nurse
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Job Description
Utilization Management Nurse reviewing authorizations, hospital stays, and transitions for Curana Health’s value-based senior healthcare programs. Supporting quality outcomes and cost-effective care remotely.
Responsibilities:
- Review and monitor members' utilization of health care services to maintain high-quality, cost-effective care
- Evaluate the appropriateness and efficiency of medical services and procedures
- Provide prior authorizations, concurrent review, proactive discharge/transition planning, and high-dollar claims review
- Perform concurrent and retrospective reviews on facility and appropriate home health services
- Monitor level and quality of care and proactively manage acutely and chronically ill patients
- Evaluate and provide feedback regarding discharge plans, covered services, and alternative levels of care
- Determine observational versus acute inpatient status during hospital prior authorization
- Engage providers in proactive discharge and transition planning
- Prepare CMS-compliant notification letters and review non-certification files
- Maintain accurate records of communications and monitor utilization reports for compliance and turnaround times
- Coordinate interdisciplinary care and continuity of care
- Issue appropriate authorizations for covered services
- Identify and report potential high-dollar/utilization cases for reserve allocation
- Recommend cost savings and quality-of-care improvements
- Clarify health plan benefits, policies, and procedures for members and providers
- Identify members for potential Chronic Care Improvement Program inclusion
- Identify and report potential quality-of-care concerns
- Work as an interdisciplinary team member within Medical Management and across departments
Requirements:
- Minimum 2 years clinical experience as RN, LPN/LVN required
- Minimum 1-year managed care or equivalent health plan experience preferred
- Demonstrated experience in health plan utilization management, facility concurrent review discharge planning, and transfer coordination required
- Medicare Advantage experience preferred
- Experience with InterQual or MCG authorization criteria preferred
- Excellent computer skills and ability to learn new systems required
- Strong attention to detail, organizational skills and interpersonal skills required
- Demonstrated ability to problem solve and manage professional relationships
- Active unrestricted Nursing license required
- Company unable to provide sponsorship for a visa at this time (H1B or otherwise)
Benefits:
- Primarily remote telephonic position
- Normal business day hours
- One weekend day per month coverage
- Opportunity to contribute to improving the health, happiness, and dignity of older adults
- Equal Employment Opportunity commitment
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