We are seeking a Michigan RN – Remote Utilization Management:
Responsibilities:
Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments.
Requirements:
- RN – unrestricted Michigan Registered Nurse license required
- 2-4 years of clinical experience – acute patient care, discharge planning, case management, and utilization review
- Clinical experience in ICU, ER, or medical surgical unit preferred.
- Utilization management experience preferred
- 1 year health insurance plan experience or managed care environment preferred.
- Above average Computer skills – MS Office, Type 35+WPM, Dual monitors, multiple systems
- Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
2. Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards.
3. Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
4. Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
5. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, Mental Health, Substance Abuse care coordination, etc.
6. Identify and document quality of care issues; resolve or route to appropriate area for resolution.
7. Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
8. Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc.
9. As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services.
10. Other duties may be assigned based on designated department assignment.
OTHER SKILLS AND ABILITIES:
- Excellent written and verbal communication skills. Excellent customer service and interpersonal skills.
- Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management.
- Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service. .
- Knowledge of applicable accreditation standards, local, state and federal regulations
Why work with us? We are a woman-owned company that values your ideas, encourages your growth, and always has your back. When you work with us you'll have training opportunities, flexible/remote work options, growth opportunities, 401K and competitive pay. Apply today! We are an EOE, all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. https://www.optechus.com/eeo_self_identification/