- Performs prospective, initial, concurrent, and retrospective reviews for all requested services to include but not limited to the following: inpatient admissions, concurrent reviews, discharges, (DME), Part B drugs, & outpatient and home health services.
- Monitors level and quality of care of services being provided and approved.
- Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
- Under the supervision of the UM Team Lead and Medical Director, evaluates and provides feedback as needed to treating physicians regarding a member's discharge and home care plans, available covered services including identifying alternative levels of care that may be covered.
- Monitors the UM system to assure compliance with turnaround time frames.
- Coordinates an interdisciplinary approach to support continuity of care. Provides UM, transfer coordination, discharge planning, and issuance of all appropriate authorizations
- Responsible for the early identification and assessment of members for potential inclusion in a comprehensive care coordination program. Refers members for care coordination accordingly.
- Actively participates in the discussion and notification processes that result from the clinical utilization reviews with members or members' representatives, facilities, requestors, and service providers.
- Prepares CMS-compliant notification letters of NON-certified and negotiated days and services within established time frames.
- Assists in the identification and reporting of Potential Quality of Care concerns.
- Licensed Registered Nurse
- Experience in the application of Milliman criteria or other evidence-based medical criteria.
- 2 - 4 years utilization review and/or managed care experience is preferred.
- Knowledge of medical problems encountered with Seniors.
- Working knowledge of Medicare Advantage Plans.
- Strong computer skills - Microsoft Office Suite & communication and interpersonal skills.
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RN Utilization Management Specialist - Park Ridge, United States - Managed Care Staffers
Description
Hybrid F/T RN Utilization Management Specialist Needed in Park Ridge, IL
Our client, a growing Medicare Advantage Plans Ins. Co. located in Park Ridge; IL has an immediate need for an experienced partially remote, direct hire full-time IL Licensed RN UM Specialist.
Hours for this position: M-F (8:30am-5:00pm) & one Sat/mo. 9am -1pm.
Job Responsibilities
Job Qualifications
If you or anyone you know is interested, qualified and currently seeking employment please e-mail an updated resume to us for immediate review and consideration.
