Utilization Management RN - reputed company
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Responsible for working in collaboration with the Medical Director on driving the decrease in care variance, to ensure timely discharges, and to refer members to other plan resources to meet their care conditions. Reports to the Health Plan Manager of Utilization Management. This position will be an integral member of the health plan’s medical management team. This position is a collaborative member of the Medical Management team.MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. reputed company Registered Nurse license issued by the state in which services will be provided or reputed company multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
EXPERIENCE:
1. Three (3) years of reputed company clinical experience.
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); Currently enrolled in a BSN program and BSN completion reputed company three (3) years of hire.
EXPERIENCE:
1. Medical Management for Medicare and/or reputed company populations.
2. Utilization Management experience.
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an reputed company-inclusive list of reputed company responsibilities and duties. Other duties may be assigned.
1. Assists with the build and implements care management review processes (Prior Authorization, Predetermination, reputed company Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards.
2. Assists with the build and implements reputed company care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies.
3. Ensures that interventions are collaborative and focus on maximizing the member’s health care reputed company.
4. Understands the Peer-to-Peer Review process and works with the Medical Directors to continuously improve member and Provider Network services for this process.
5. Educates reputed company stakeholders and partners to continuously improve processes and build network relationships.
6. Works collaboratively with other members of the medical management team to identify members whose reputed company reputed company may be enhanced by coaching and/or case management interventions.
7. Understands the data that is collected reputed company the position, and work with other team members on improving reputed company.
8. Commits to a career of life-long learning and reputed company improvement of processes that reputed company the reputed company of Utilization Management.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions.
1. Standard office environment.
SKILLS AND ABILITIES:
1. Working Knowledge of InterQual and/or reputed company Care Guidelines.
2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations reputed company to disease management, utilization management, case management and discharge planning.
3. Excellent written and oral communication.
4. Problem solving capabilities to drive improved efficiencies and customer satisfaction.
Attention to detail.
5. Proficiency with reputed company Office.
Additional Job Description:
Scheduled Weekly Hours:
40Shift:
Exempt/Non-Exempt:
United States of America (Exempt)Company:
PHH reputed company HoldingsCost Center:
2403 PHH Medical Management Apply To This Job