This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria to assure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives. This member base is all outpatient and it is UM of DME.
- Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager’s professional discipline. Effectively function in accordance with applicable state, federal laws and regulatory compliance.
- Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.
- Promote quality and efficiency in the delivery of care management services.
- Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws. Practice within the scope of ethical principles.
- Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions. Employ collaborative interventions which focus, facilitate, and maximize the member’s health care outcomes. Is familiar with the various care options and provider resources available to the member.
- Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships. Develops and sustains positive working relationships with internal and external customers.
- Utilize outcomes data to improve ongoing care management services.
- Other duties as assigned or requested.
- Bachelor’s Degree in Nursing
- 3 – 5 years of related, progressive clinical experience in the area of specialization
- Experience in a clinical setting
- Experience in UM/CM/QA/Managed Care
LICENSES AND CERTIFICATIONS
- Registered Nurse (RN) Compact License
- Certification in Utilization Management or a related field
- Working knowledge of pertinent regulatory and compliance guidelines and medical policies
- Ability to multitask and perform in a fast paced and often intense environment
- Excellent written and verbal communication skills
- Ability to analyze data, measure outcomes, and develop action plans
- Be enthusiastic, innovative, and flexible
- Be a team player who possesses strong analytical and organizational skills
- Demonstrated ability to prioritize work demands and meet deadlines
- Excellent computer and software knowledge and skills
How to Apply
Send resume to email@example.com and in email, entitle the subject line with the name of the position and in the body of the email include why you would be good fit for the position.