Utilization Management Nurse RN

Overview

Collaboration with Managed Care Organizations (MCO) and care providers is vital to ensure care is being delivered in the right setting at the right time.

Responsibilities

• Collaborate regularly and maintain open communication with leadership, patients, families, internal care givers, and external Utilization Management Nurses.
• Coordinate internal and external health care team activities related to resident care, transitions and discharge planning with agencies, and other healthcare organizations.
• Conduct initial baseline assessment of resident care needs and communicate that effectively to the Managed Care Organization (MCO) ensuring all aspects of care services are communicated accurately.
• Verify all care needs and the authorization for services and outliers.
• Communicate/collaborate with the Managed Care Organization (MCO) at required intervals as determined by the MCO
• Negotiate appropriate levels based on services provided and contractual arrangements with the facility and the MCO.
• Document all authorizations and continued stay activity in Case Management software to ensure appropriate reporting and billing
• Prepare all Managed Care documentation to facility accurate billing.

Qualifications

• Registered Nurse (RN) in good standing with required current state license.
• Associates degree required, but Bachelor’s degree preferred.
• Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual.
• Minimum of three (3) years related case management experience.
• Minimum of three (3) years of hospital, SNF or Acute Rehab clinical experience
• Certified in Case Management through ACMA, CCMC or other credentialed agencies, preferred or willing to obtain after one year of employment.
• Knowledge of Medicare payment methodology and the MDS RUG system. Previous experience with MDS and assessment preferred