- Review and track emergency admissions to identify appropriate level of care for acute and post-acute inpatient services.
- Perform concurrent review and/or admission review on all hospital admissions using InterQual criteria guidelines.
- Request and review medical records to identify appropriate acute care days and approve or refer questionable days to the medical director for decision.
- Serve as resource for physicians, PCPs, Utilization Review departments and all medical providers.
- Identify trends that impact on utilization at hospitals during the review process and help resolve them.
- Maintain departmental and regulatory timeframes for utilization decisions.
- Maintains collaborative and effective cross- functional training within the Utilization Management Department Utilization management perform after hour's on-call coverage.
- Successful and timely completion of assignments in accordance with departmental and Company operational objectives and seeks feedback on performance. Responsible to for after hour on call shifts as needed
- Licensed Registered Nurse, must have an active license to practice professional nursing in the Commonwealth of Pennsylvania
- 2 years medical/surgical, utilization review and emergency room experience.
- Thorough understanding of managed care systems and utilization review criteria
- Recent experience in a hospital, insurance company, or independent review company in utilization, quality review or case management
- Knowledge of health insurance including Medicare, Medicaid and managed care
- Excellent telephone and verbal/written communication skills.
- Proficient use of Microsoft Office suite (Word, PowerPoint, Excel) required.
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Matron Job - Philadelphia, PA, United States - Health Partners Plans
Description
Utilization Management NurseWhy Choose Jefferson Health Plans?
We are an award-winning, not-for-profit health maintenance organization offering Medicaid, Medicare, and Children's Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members.
We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.
While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.
Impact on the communities we serviceWe are seeking a talented and enthusiastic Utilization Management Nurse to join our team
The Utilization Management Nurse is responsible assure cost effective, quality utilization management in the acute level of care setting for the pediatric or adult population in the post-acute inpatient setting (i.e.,SNF/Rehab).
Also, responsible to review clinical information provided by facilities and communicates UM determinations maintaining timeliness.As the Utilization Management Nurse, your daily duties may include:
