The Utilization Management Nurse is responsible for the delivery of the Utilization Management process to include: making
clinical recommendations regarding medical necessity for admission, continued stay and the development/implementation of a comprehensive case management treatment plan.
Essential Functions
Responsible for the telephonic and fax delivery, of the Utilization Management process to include: assessing, planning, implementing and, coordinating clinical recommendations regarding medical necessity for admission, continued stay and the development / implementation of a basic case management treatment plan.
- Collects in-depth information regarding a patients clinical history, prognosis, treatment plan, response to treatment, access to care, access to personal and community resources, utilization of care, personal coping mechanisms, learning needs and financial constraints.
- Determine specific short and long-term goals, objectives, and interventions with accompanying timeframes..
- Screens for cases which do not meet the client specific guidelines, i.e. physician developed criteria, Medicare and/or Medicaid guidelines and refers them to the Medical Panel accordingly.
- Establishes a quality check date using client specific guidelines.
- Utilizes nursing experience and judgment in addition to the client specific guidelines when determining medical necessity and quality check dates.
- Performs multiple tasks within the review process including knowledge of different systems, reviewing for multiple clients and the ability to interpret and apply multiple benefit configurations to the review process.
- Monitors daily work flow queues and performs necessary calls to ensure completion of reviews according to department procedure.
- Responsible for maintaining expected quality standards, -Offers suggestions for improvement in the review process.
- Maintains a courteous and professional manner in all interactions, whether with clients or co-workers.
- Perform discharge planning for the member if necessary and allowed by client contract.
- Other duties as assigned
- Security responsibilities
Required Skills
Requirements
- Associate’s degree in nursing Bachelor’s degree preferred.
- Unrestricted & active Kentucky Registered Nurse License.
- A minimum of three years clinical nursing experience preferred.
- A minimum of three years utilization management experience working with individuals with complex care needs experience preferred.
- Intermediate level skills in Microsoft applications (Excel, Word, Outlook, and Windows environment).
- Excellent verbal and written communication skills.
- Organization and time management skills are essential.
- Must be able to successfully complete any required pre-employment testing.
Required Experience