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Health Services WellCare - Nursing Careers

RN Utilization Manager Job

Full Job Title: RN Utilization Manager

Job Number: 1800949

Location: Columbia, MD

Date Posted: 2-8-2018

The RN Utilization Manager maximizes the components of the in-patient and out-patient settings by utilizing care coordination tools, criteria and protocols to:
  • Provide members with chronic and acute conditions the support, education and assistance in the prevention and/or maintenance of their disease and/or health and wellness state;
  • Increase member compliance with treatment plans;
  • Engage community resources to support the member's optimal functioning; and
  • Improve collaborative coordination of care to affect waste and inefficiency.

  • Review activities that take place during a patient's hospital stay and/ or in a home or community setting to include review of evidence that care is being delivered at the appropriate level.
  • Review evidence that discharge planning began at admission or start of services.
  • Coordinate discharge planning needs with facility, health services providers and member.
  • Review continued need for inpatient days with authorized length of stay extensions, if appropriate, based on patient's acuity requiring acute, observation, skilled unit or rehabilitation stays.
  • Review cost and/or hospital stay data to determine stop-loss attachment level status.
  • Communication with other Health plan case managers for follow up needs with documentation in the Health Service's system.
  • Facilitate provider contact as needed to coordinate member's care needs.
  • Identify high risk members for case management and work with member, physician and other health care providers to establish a plan of care to meet the member's individual needs.
  • Provide telephonic and/or face to face follow up with members for case management services once discharged from facility.
  • Conduct or oversee "Welcome Home" calls to members post discharge from inpatient or other levels of care and ensure documentation is kept current in the Health Services system.
  • Phone contact and/or face-to-face with identified members to explain the program, assess needs, educate member regarding the disease as appropriate.
  • Phone contact and/or face-to- face to instruct the member on how to access the program resources, suggest and/ or arrange follow-up including mailing of educational materials, contact with community resources, and physician follow up visits; document the contact into the Health Service's system.
  • Perform home visits, with verbal and documented permission from provider and member and/or caregiver, for member support, when appropriate.
  • Review the medical record to ensure medical necessity.
  • Perform hands-on assessments, teaching and medication setup -- but not treatment -- within the nurse's scope of practice.
  • Consult and work closely with the Medical Director regarding care that doesn't appear to meet medical necessity.
  • Conduct daily tracking of caseload as assigned.
  • Prepare for and attend Local Physician Organization committee meetings as assigned.
  • Comply with all departmental policies and procedures.
  • Participate in departmental and company in-services as appropriate.
  • Comply with Customer Service expectations as applicable to the Department and Health Plan.
  • Collaboration with member's Providers to get all information required to approve requested item.
  • Take calls from members and providers and give them appropriate information to help expedite services.
  • Comply with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable, and defined in the Universal American Corporate and department policies.
  • And all other duties assigned by the manager and/or supervisor.

Required Skills:

  • Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas.
  • Organizational skills with the ability to handle multiple tasks and/or projects at one time.
  • Customer service skills with the ability to interact professionally and effectively with providers, third party payers, physicians, and staff from all departments within and outside the Company.
  • Analytical and interpretation skills including departmental, utilization, financial and operations data.
  • Decision-making skills with the ability to investigate and weigh alternatives and select the course of action that provides the greatest benefit to the organization.
  • Creative thinking skills with the ability to ask the needed bigger-picture questions that lead to process and team improvements.
  • Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time.
  • Problem solving skills with the ability to look for root causes and implementable, workable solutions.
  • Interpersonal skills with the ability to work in a fast-paced environment and participate as an independent contributor with little supervision or as an active team member depending on the situation and needs.
  • Must have a track record of producing work that is highly accurate, demonstrates attention to detail, and reflects well on the organization.

Required Experience:

  • RN with current licensure.
  • Maintains a valid driver's license for any required facility on-site and home visits.
  • Experience working with the geriatric population is required.
  • Two years of acute care and/or case management experience within a hospital, home health setting or managed care company.
  • Personal computer experience should include working with Microsoft Word, Excel, PowerPoint and Outlook at the intermediate level at a minimum.

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Last Updated On: 12/9/2015