Telephonic Utilization Management & Case Management Operations Registered Nurse | Remote

Utilization Management & Complex Case Manager, Registered Nurse | Remote

Are you passionate about ensuring patients receive the care they need? Join our team as a Utilization Management & Complex Case Management Nurse, where you will play a crucial role in reviewing and approving authorization requests for appropriate care and provide comprehensive case management services for beneficiaries with multiple or complex conditions. You will follow established guidelines and policies, and when necessary, forward requests to the appropriate stakeholders. You'll also use your clinical knowledge, communication skills, and collaborative spirit to help our beneficiaries regain their optimum health or improve their functional capabilities. This involves performing comprehensive assessment, care planning, implementation, monitoring, and evaluation activities via telephonic contact and digital outreach.

Our team works diligently to ensure that beneficiaries progress toward desired outcomes with quality care that is medically appropriate and cost-effective. Our goal is to assist beneficiaries in regaining their optimal health or improved functional capability, support effective self-care management, and promote access to healthcare services and community resources.

Key Responsibilities: 

• Review authorization requests using clinical judgment and evidenced-based clinical decision support criteria to ensure medical necessity and appropriate level of care. 
• Assesses services for beneficiaries to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. 
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures. 
• Conducts authorization reviews to determine financial responsibility for the payer and its beneficiaries. 
• Approve services or refer cases to internal stakeholders based on findings. 
• Makes appropriate referrals to other clinical programs. 
• Refers appropriate authorization requests to and collaborates with Medical Directors. 
• Educate providers on utilization and medical management processes. 
• Enter and maintain clinical information in various medical management systems. 
• Make evidenced-based independent decisions regarding work methods, even in ambiguous situations, with minimal direction. 
• Analyzes clinical service requests from beneficiaries or providers against evidence based clinical guidelines. 
• Processes requests within required timelines. 
• Collaborates with multidisciplinary teams to promote the care model. 
• Adheres to all UM policies and procedures, federal, state and regulatory guidelines.
• Conduct a comprehensive assessment with beneficiaries and analyze assessment findings to identify and prioritize clinical, psychosocial, and behavioral concerns and potential gaps in care. 
• Develop and document a case management care plan in direct collaboration with the beneficiary, the beneficiary's family or significant other(s), the primary physician and other health care providers. Identify and include key concerns, needs, and preferences of the beneficiary and family/caregiver.  
• Document identified issues, prioritized and individualized goals (long & short term), evidence-based interventions, collaborative approaches and resources, anticipated time frames, and barriers to achieving goals in the care plan.
• Coordinate and implement the activities specified in the care plan to provide optimal benefits coverage as well as promote continuity of care and integration of services for the beneficiary across care transitions.  Collaborate and communicate with the beneficiary, family, significant other(s), physician, and other health care providers to accomplish the goals on the care plan.
• Monitor and continually evaluate the care plan on a scheduled basis to ensure it remains effective and to determine if desired outcomes are met and the goals are achieved.  Revise and update the care plan as needed in collaboration with the beneficiary and the health care team.
• Collaborate with beneficiaries and their support system/caregivers, providers, the multi-disciplinary team, and health care and community resources throughout the case management process.
• Be familiar with and understand the scope of professional licensure and carry out case management activities consistent with the scope of this licensure.  

Work schedule Monday - Friday 5 days x 8 hours  

Shift time for remote telephonic work is aligned to state of residence and time zone:   

Pacific Time Zone          9 am - 6 pm PT

Mountain Time Zone     10 am - 7 pm MT

Central Time Zone         11 am - 8 pm CT

Eastern Time Zone        11 am - 8 pm ET

Qualifications: 

Required 

• Current, unrestricted RN license in of residence with multi-state privileges (an active compact state license), or the ability to obtain multi-state privileges in the state of residence.
• 3+ years of experience as a nurse in a clinical setting.
• 2+ years’ experience performing the utilization review for a health plan or inpatient facility.
• 1+ year of experience as a case manager for a health plan or inpatient facility. 
• Strong technical proficiency with MS Office Suite Word, Excel, Power Point, Microsoft Teams and SharePoint and ability to navigate multiple systems under periods of high volume. 
• Must hold United States Citizenship status.
• Ability to obtain Federal Security Clearance required. Current DOD Security Clearance preferred.
• Secure, private home office work environment.

Preferred

• Bachelor’s degree in nursing from an accredited college, university, or school of nursing.
• Experience working in a NCQA and URAC accredited program. 
• Previous experience in Hospital Acute Care, Prior Auth, Utilization Review / Utilization Management and knowledge of InterQual and/or MCG guidelines.
• Health Plan experience working with large carriers. Previous Federal government plan program experience such as Tricare, Medicare Medicaid and commercial health insurance experience.
• Active, Certified Case Management Certification (CCM).
• Experience working remotely.