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Utilization Management Nurse

ArchWell Health -
Remote

Apply Now

Job Details

Full-time

Qualifications

RN License
Associate of Science in Nursing
Evidence-based practice
Utilization management
Medical treatment knowledge
Resource utilization in healthcare
Associate Degree in Nursing
Cross-functional communication

Full Job Description

Job Summary:
Reporting to the Director of Utilization Management, the Utilization Management Nurse is responsible for ensuring that patients receive appropriate, cost-effective care by reviewing and evaluating medical services, treatments, and procedures. This role identifies trends for opportunities to educate and collaborate with healthcare providers, patients, and specialists to optimize resource utilization and improve patient outcomes.

Duties/Responsibilities:

Conducts prospective, concurrent, and retrospective utilization reviews for medical necessity to ensure treatment and services are appropriate and necessary by reviewing medical records and treatment plans.
Works collaboratively with healthcare providers and Medical Directors to provide guidance on approvals or requests for health plan determination reviews as applicable utilizing CMS clinical guidelines and insurance policies.
Maintains accurate and detailed records of reviews, interventions, and communications to ensure adherence to health plan requirements and organizational policies.
Analyze utilization trends to ensure progress towards organizational goals
Educates healthcare providers and patients regarding appropriate levels of care and service criteria and guidelines.
Collaborates with Network and specialists to identify opportunities to educate on value-based care, resolve specialty gaps by markets, improve cost-effectiveness and coordination of care to meet patient needs.

Required Skills/Abilities:

Strong knowledge of utilization management functions in value-based care, including data analysis, claims review, reimbursement practices, and medical records reviews.
Thorough, in-depth knowledge of evidence-based practice, legal rules and regulations and best practices in healthcare
Ability to effectively leverage business and organizational knowledge within and across functional areas
Must possess a high degree of emotional intelligence and integrity, driven and focused work ethic
Continuous desire to learn and embrace new methods; ability to adapt and be resilient.
Self-starter with the ability to think creatively and work effectively
Ability to build a relationship and work effectively with various seniorities and diverse populations.
Excellent critical reasoning, decision-making, and problem-solving skills to make informed decisions and ensure effective resource utilization while maintaining quality patient care.
Willingness and ability to travel, up to 20%

Education and Experience:

AA/AS degree in Nursing required; BA/BS degree in Nursing (BSN) or Healthcare Administration preferred
A valid, active Registered Nurse (RN) license in state(s) of employment required
A minimum of 3 years’, current direct utilization management required
Work in an acute care facility, community-based clinic, public health department or specialization with the senior population preferred
Proficient PC skills
Fluency in Spanish or other languages spoken by people in the communities we serve is desirable, but not required

ArchWell Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to their race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected classification.

Apply Now

Refine Your Search

registered nurse jobs in remote $

Utilization Management Nurse

Triage RN – Hospice Evening or Night Shifts - FT

Utilization Review RN-Remote

Utilization Management Nurse (CA)

Registered Nurse - Freelance AI Trainer Project

Flu Shot Nurse

RN, Patient Navigator REMOTE

Clinical Documentation Specialist (CDI)

Med Mgmt Nurse (contract)

Utilization Review Nurse RN Part-Time

Registered Nurse (Fully Remote) (0600-1800 EST)

Remote Registered Nurse Experts

Nurse Appeals (contract)

Utilization Review Nurse

RN-RPM

Legal Nurse Researcher (Life Care Planning)

Part-Time RN

Denials & Appeals Administrator (RN)

Adult Inpatient Nurses (RN)

Clinical Review Nurse

I want to receive the latest job alert for registered nurse in remote $

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