Registered Nurse Reviewer Utilization Management

Job Description:

The RN Utilization Management Reviewer I utilizes clinical expertise and critical thinking skills to conduct utilization review care management screenings, assessments, and evaluations while prioritizing stewardship of resources. This role is responsible for developing and implementing a plan that supports cost effective, extraordinary care. This position works collaboratively with patients, patient families/significant others, healthcare providers, insurers, and other involved parties to ensure compliant, efficient, effective, and patient-centered utilization review services. Essential Functions Reviews and investigates medical record and applies clinical expertise to assure appropriate benefit utilization, and medical necessity as relates to requested services, authorization history, and treatment plan. Uses in-depth knowledge of medical procedures, treatments, and diagnosis to apply evidence-based guidelines (e.g. InterQual/MCG) and medical policies for prior authorization and post service reviews. Follows the applicable regulatory guidelines (NCQA, CMS, State) and ensures timely review with clear accurate communication to members and requesting providers. Based on medical necessity and clinical best practice proactively engages with providers to ensure safe and efficient medical care, appropriate care setting, and safe transitions of care referring to alternate programs as applicable. Collaborates with physicians, internal staff, members, and families to assist in expediting the requested authorizations, and directs toward medically necessary care and the correct level/setting for services requested. Adheres to regulatory guidelines and timely communication with members, providers, and internal/external partners. Engages proactively with members and providers for safe, efficient care and transitions as applicable to continuity of care, redirection, and authorization determination. Resolves queries regarding authorizations, treatment plans, and medical necessity determinations. Mentors and guides the UM LPN on clinical questions and application of resources. Skills Utilization Management Clinical Expertise Investigative Acumen Medical Diagnosis & Treatment Medical Terminology Time Management Problem Solving Quality Care Resourceful Communication Minimum Qualifications Current Registered Nurse (RN) license in state of practice, and compact licensure within service area states. Bachelor of Science in Nursing (BSN) from an accredited institution (degree verification required.) RNs hired or promoted into this role must obtain their BSN within four (4) years of hire or promotion. Demonstrated experience in care management/navigation or closely related field including utilization management, discharge planning, managed care, health promotion, health coaching, behavioral health, or patient educator role. Demonstrated clinical nursing experience in an inpatient hospital setting, and familiarity with hospital patient-related terminology and processes. Demonstrated understanding of disease management including treatment, length of stay, identifying barriers to delivery of care and any variation. Demonstrated excellent written and verbal communication skills. Ability to work independently and be flexible in a rapidly changing environment. Proficiency with basic computer hardware set-up, ability to customize computer settings and use multiple monitors, and capable of independently troubleshooting internet and applications. Preferred Qualifications One (1) year experience in care management/navigation or closely related field including utilization management, discharge planning, managed care, health promotion, health coaching, behavioral health, or patient educator role. Three (3) years of experience and expertise working in clinical nursing in an ambulatory care setting, community health or home care. Bachelor of Science in Nursing (BSN) from an accredited institution. Case Management, Utilization Management, or Health Care Quality Certification. Experience working with third party payers. Experience working successfully working in a remote environment or using Advanced Microsoft Suite, including Teams (chat, whiteboard, task tracking) & Outlook. Physical Requirements Ongoing need for employee to see and read information, labels, documents, monitors, identify equipment and supplies, and be able to assess customer needs. Frequent interactions with providers, colleagues, customers, patients/clients and visitors that require employee to verbally communicate as well as hear and understand spoken information, needs, and issues quickly and accurately. Manual dexterity of hands and fingers to manipulate complex and delicate supplies and equipment with precision and accuracy. This includes frequent computer use for typing, accessing needed information, etc.

For roles requiring driving:

Expected to drive a vehicle which requires sitting, seeing and reading signs, traffic signals, and other vehicles.

Location:

Nevada Central Office Work City:

Las Vegas Work State:

Nevada Scheduled Weekly Hours:

40 The hourly range for this position is listed below. Actual hourly rate dependent upon experience. $40.39 - $60.96 We care about your well-being - mind, body, and spirit - which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged. Learn more about our comprehensive benefits package here. Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. At Intermountain Health, we use the artificial intelligence ("AI") platform, HiredScore to improve your job application experience. HiredScore helps match your skills and experiences to the best jobs for you. While HiredScore assists in reviewing applications, all final decisions are made by Intermountain personnel to ensure fairness. We protect your privacy and follow strict data protection rules. Your information is safe and used only for recruitment. Thank you for considering a career with us and experiencing our AI-enhanced recruitment process. All positions subject to close without notice. Headquartered in Utah with locations in six primary states and additional operations across the western U.S., Intermountain Health is a nonprofit system of 34 hospitals, 400+ clinics, a medical group of more than 4,800 employed physicians and advanced care providers, a health plan division called Select Health with more than one million members, and other health services. Helping people live the healthiest lives possible, Intermountain is widely recognized as a leader in clinical quality improvement and efficient healthcare delivery. Join our world-class team and embark on a career filled with opportunities, strength, innovation, and fulfillment. To find out more about us, head to our career site here. Sign up for job alerts! Click 'sign in' at the top right corner, create a candidate account, and when we have opportunities that meet your interests, you will receive an email with the job details. Intermountain Health strives to make the application process accessible to all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact 1-800-843-7820 or email recruitment@imail.org. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications. Introduce yourself to our Talent Acquisition team and we will get in touch if there is a role that seems like a good match. Intermountain Health's PEAK program supports caregivers in the pursuit of their education goals and career aspirations by providing up-front tuition coverage paid directly to the academic institution. The program offers 100+ learning options to choose from, including undergraduate studies, high school diplomas, and professional skills and certificates. Caregivers are eligible to participate in PEAK on day 1 of employment. Learn more. The primary intent of this job description is to set a fair and equitable rate of pay for this classification. Only those key duties necessary for proper job evaluation and/or labor market analysis have been included. Other duties may be assigned by the supervisor. All positions subject to close without notice. Thanks for your interest in continuing your career with our team!