Utilization Manager RN Job at Nashville

Job Description

Utilization Manager RN

Job ID 2013-23529 # Positions 1
Location US-TN-Nashville
Search Category Nursing
Type Regular Full-Time (30+ hours) Posted Date 7/25/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for evaluating the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Responsible for clinical review of all acute and sub acute services for appropriateness based on medical criteria, the management of healthcare resources necessary and appropriate for achievement of desired acute and sub acute outcomes, and the coordination of alternative levels of care for members. Serves as a patient advocate, seeking and coordinating creative solutions to patients health care needs without compromising quality outcomes.

Responsibilities:

1. Performs on-site and/or telephonic review of acute and sub acute services.

2. Predicts and plans for patients needs from pre-admission, through acute and sub acute care and post-discharge, in collaboration with the member.

3. Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.

4. Acts in conjunction with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs.

5. Coordinates with appropriate discharge planning team members, facility utilization management department, physicians and members to coordinate timely discharges.

6. Participates in Quality Improvement Process; tracks and reports trends of inappropriate utilization of resources to the Medical Director; identifies and reports any quality or utilization issues to the Medical Director.

7. Acts in conjunction with the clinical team related to discharge planning (e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy), durable equipment and disposable supplies.

8. Documents all activities in the appropriate system(s) on a timely basis.

9. Participates in rounds with the Medical Director.

10. Reviews health plan appeal items for concurrent and retrospective reviews as required and requested.

11. Monitors and facilities appropriate utilization of resources using appropriate clinical criteria.

12. Participates in a multi-disciplinary clinical team to achieve positive member outcomes; Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.

13. Other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Nursing Diploma.
- Associates Degree in related Health/Nursing field.

Preferred:
- Bachelors Degree in related Health/Nursing field.

Years and Type of Experience Required:

Required:
- Minimum of two years of utilization management or hospital/acute care experience.

Preferred:
- Minimum of three years experience in health care, case management, discharge planning, utilization management, or behavioral health.
- Experience working on the community level and with community agencies.

Certifications or Licensures

Required:
- RN
- Must possess a valid drivers license and access to a motor vehicle.

Preferred:
- Certified Professional Healthcare Management

Language Skills

Required:
- English

Preferred:
- Bilingual

Functional Competencies
- Proficient in the use of Microsoft Office tools. Able to use basic office equipment such as telephone, fax machine and copy machine. Use of Internet and working knowledge in a windows environment to include navigation skills using a mouse, keyboard and number pad Ability to review and draft correspondence in email system and word processing systems.
- Experience working with utilization management data systems.

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to Amerigroup travel policies and procedures.

CB1

ermHO
Healthcare Operations

Job Requirements

 
Country: USA, State: Tennessee, City: Nashville, Company: WellPoint.