Utilization Management RN Full-Time Remote Position

Our take on this role

About this role

Review medical necessity for health plan members’ inpatient and outpatient services, conduct telephone assessments, and communicate review outcomes to providers. Work from home Monday–Friday, 9 a.m.–6 p.m. ET, for 40 hours per week.

What could you bring from clinical work?

• Nurses: Reviewing hospital patients’ clinical information could help you interpret medical-necessity criteria and support recommendations for inpatient and outpatient services.

Full job description from HealthCare Strategies, Inc.

Utilization Management RN (M-F FROM YOUR HOME OFFICE)

HealthCare Strategies

Description

Do you want to work from the comfort of your own HOME? Do you want to work for a progressive company that is a leader in their industry?
F/T 40-hour/week Position
Monday - Friday
Hours: 9am - 6pm ET
. JOB DESCRIPTION:

• Responsible for the collection of personal and clinical information on participating Plan members for the purpose of:
• Providing patient education services.
• Rendering initial determinations of medical appropriateness for communication to the health benefit plan.
• Identifying individuals whose health and/or expenses may be positively affected through application of Large Case Management.

SPECIFICS:

• Perform telephonic Clinical Assessments
• Obtain appropriate information from health care provider and or patient or family regarding planned procedure, admission, continued stay or discharge plan.
• Interpret nationally recognized criteria to support recommendations for inpatient and outpatient services.
• Identify and refer individuals whose health and/or expenses may be positively affected through the application of Case Management.
• Document each call completely, accurately and promptly into the computer system.
• Follow documented policies and procedures for the handling of confidential materials and/or patient specific information.
• Answer direct telephone calls related to medical services in order to determine if prior authorization is required for the requested services.
• Retrieve and acknowledge messages requesting medical services from voicemail.
• Complete all medical necessity reviews and communicate outcomes to providers within the appropriate time frames.
• Provide educational materials and direct callers to community services when indicated.
• Provide coverage for professional colleagues.

REQUIREMENTS:

• Active, unrestricted RN License
• Minimum internet speeds of 25Mbps download; 25 Mbps upload
• 1+ years experience in hospital setting

ABILITIES/SKILLS:

• Strong verbal communication skills
• Problem-solving and decision-making skills
• Ability to carry out detailed written or verbal instructions independently
• Proficiency with Microsoft Office Suite (Outlook, Word)

PREFERRED:
* 1+ years previous UM experience

* Experience using Interqual criteria.

During our over 40 years in business, HealthCare Strategies has earned a reputation for delivering quality services as a medical management provider and now through technology platforms by offering next generation, informatics-driven, health management services used singularly, or in tandem, with our highly effective clinical programs.

Monday - Friday; 40 hours/week. Hours: 9a - 6p ET