Utilization Management RN
BroadPath is hiring Registered Nurses to work from home! This position provides support and execution of programs and tactics used to influence provider and health plan behaviors in order to achieve right care in the right place at the right time and the appropriate cost. Plans and provides support for health plan to align with the objectives of triple aim. This position is responsible to process health plan medical pre-service requests, provide case management, care coordination and perform utilization management duties within the appropriate time period as outlined in the Medical Management Program Descriptions, and in accordance with all federal and state regulations.
- Manages health Plan across the health care continuum to achieve optimal clinical, financial, operational, and satisfaction outcomes.
- Provides pre-service determinations, concurrent review, and case management functions within Medical Management. Ensures quality of service and consistent documentation.
- Works collaboratively with both internal and external customers in assisting health Plan and providers with issues related to prior authorization, utilization management, and/or case management. Meets internal and external customer service expectations regarding duties and professionalism.
- Performs transfer of accurate, pertinent patient information to support the pre-service determination(s), the transition of patient care needs through the continuum of care, and performs follow-up calls for advanced care coordination. Documents accurately and timely, all interventions and necessary patient related activities in the correct medical record.
- Evaluates the medical necessity and appropriateness of care, optimizing health Plan outcomes. Identifies issues that may delay patient services and refers to case management, when indicated to facilitate resolution of these issues, pre-service, concurrently and post-service.
- Provides ongoing education to internal and external stakeholders that play a critical role in the continuum of care model. Training topics consist of population health management, evidence based practices, and all other topics that impact medical management functions.
- Identifies and refers requests for services to the appropriate Medical Director and/or other physician clinical peer when guidelines are not clearly met. Conducts call rotation for the health plan, as well as departmental call rotation for holiday.
- Maintains a thorough understanding of each plan, including the Evidence of Coverage, Summary Plan Description authorization requirements, and all applicable federal, state and commercial criteria, such as CMS, MCG, and Hayes.
- Has freedom to determine how to best accomplish functions within established procedures. Confers with supervisor on any unusual situations. Positions are entity based with no budgetary responsibility. Internal customers: All levels of nursing management and staff, medical staff, and all other members of the interdisciplinary health care team. External Customers: Physicians and their office staff, payers, community agencies, provider networks, and regulatory agencies.
- Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Banner Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.
- Active AZ RN License
- A bachelor’s degree or equivalent experience.
- Requires proficiency level typically achieved with five years of clinical experience.
- Must have a working knowledge of care management, acute care and/or home care environments, community resources and resource/utilization management.
- Must demonstrate critical thinking skills, problem-solving abilities, effective communication skills, and time management skills.
- Must demonstrate ability to work effectively in an interdisciplinary team format. Must be able to work flexible hours and take rotating call after hours.
- Certification(s) related to field, such as Certified Case Manager (CCM), MCG Certification(s), RN-BC Registered Nurse Case Manager, Certification in Managed Care Nursing (CMCN).