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Utilization Management Rn
Location:
Indianapolis, IN
Description:
SUMMARY: Utilization Management RN to be responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. MAJOR JOB DUTIES AND RESPONSIBILITIES: Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures. Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract. Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process. Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning. Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications. Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards. EDUCATION/EXPERIENCE: Requires an AS/BS in nursing; 2 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) required. Qualification Assessment Utilization Management and/or Milliman Care Guideline experience is preferred. Acute inpatient nursing experience is required. Must be comfortable working in a virtual environment with strong IT/computer skillset to include Excel, Microsoft Outlook, Microsoft Teams. Fast learner who can adapt to frequent process changes.
Company:
Professional Management Enterprises
Posted:
November 10 on TopUSAJobs
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More About this Listing: Utilization Management Rn
Utilization Management Rn is a Nurse & Healthcare Registered Nurse Job at Professional Management Enterprises located in Indianapolis IN. Find other listings like Utilization Management Rn by searching Oodle for Nurse & Healthcare Registered Nurse Jobs.
Utilization Management Rn is a Nurse & Healthcare Registered Nurse Job at Professional Management Enterprises located in Indianapolis IN. Find other listings like Utilization Management Rn by searching Oodle for Nurse & Healthcare Registered Nurse Jobs.