Skip to main content
Health Services WellCare - Nursing Careers

Utilization Management - RN Job

Full Job Title: Utilization Management RN

Job Number: 1704903

Location: Statewide, NY

Date Posted: 10-25-2017

Oversees utilization management activities by assessing the necessity and efficiency of services through systematic monitoring of medical necessity and quality, while maximizing the appropriate level of care that correlates to the member's benefit plan. Works collaboratively with providers and facilities to determine, coordinate and authorize post-acute care services and provide referrals to clinical and social support services, including but not limited to, case/disease management, other providers within the plan's network and with community based resources.

Essential Functions:
  • Telephonically reviews medical information in order to determine the medical necessity of continued stay according to review standards. Determines whether treatments are consistent with member's diagnosis and appropriate level of care.
  • Ensures that services provided to eligible members are within benefit plan and appropriate contracted providers are being utilized.
  • Determines medical necessity and length of stay based on the consistent application of CMS criteria, Interqual criteria, and Clinical Coverage Guidelines and communicates with Medical Directors for those reviews that fall outside of approvals.
  • Initiates and continues direct communication with health care providers involved in the care of members, including treating physicians, IPA and/or hospitals, to share information and collaboratively establish acute and post-acute treatment plans for hospitalized members.
  • Assesses and coordinates simple discharge planning (short-term rehabilitation, homecare etc) with physicians, caregivers and ancillary providers to support the member's continuity of care needs.
  • Interacts with facility discharge planners/utilization management team to coordinate medical treatment plan, and identifies opportunities for optimizing clinical outcomes through referrals to specialty care programs or an alternate level of care.
  • Identifies members at high risk for complicated medical treatment plans, and/or repeat admissions potential and refers them to the appropriate case and disease management teams.
  • Coordinates authorization and/or delivery of post-acute care services, including, but not limited to referrals to case and disease management, home health, medical equipment, skilled nursing facilities and other community based services.
  • Identifies quality of care issues, and reports to appropriate health plan Quality department representative. Ability to follow and apply all necessary regulatory requirements for assigned market.
  • Oversees the appropriate utilization management of services requested.
  • Documents clinical updates, authorizations and referrals in the health plan medical management system adhering to health plan documentation standards.
  • Assists with implementation of healthcare initiatives in market.
  • Assists in implementation of specific strategies that improve the quality and outcomes of care in market.
  • Performs other duties as assigned.
Additional Responsibilities:
  • Nurse will be based out of home or office, with possible travel required to assigned hospitals and facilities. Valid driver's license, without restrictions, is required.
Candidate Education:
  • Required A High School or GED
  • Preferred A Bachelor's Degree in a related field
Candidate Experience:
  • Required 2 years of experience in a clinical setting with general nursing exposure in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews
  • Preferred Other Care management experience in a managed health care setting
Candidate Skills:
  • Ability to work independently Ability to work independently, handle multiple assignments and prioritize workload
  • Ability to multi-task
  • Demonstrated time management and priority setting skills
  • Demonstrated interpersonal/verbal communication skills
  • Demonstrated written communication skills
  • Ability to create, review and interpret treatment plans
  • Demonstrated problem solving skills
  • Knowledge of healthcare delivery
  • Ability to effectively present information and respond to questions from families, members, and providers
  • Ability to effectively present information and respond to questions from peers and management
Licenses and Certifications:
  • Required Licensed Registered Nurse (RN)
Technical Skills:
  • Required Proficient in MS Word, Excel and Outlook

Back to top

Join Our
Talent Network

and receive job alerts
Click Here
Last Updated On: 12/9/2015