Posted in General Business 5 days ago.
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Location: Pittston, Pennsylvania
Southwestern Health Resources is seeking to hire a Utilization Manager Reviewer Registered Nurse to support our Southwestern Health Resources Utilization Management Department.
The address is 900 Jerome Street, Fort Worth Texas, 76104
Salary range is $34.74/hour - Max 50.05/hour - based on relevant experience.
• Full-time: 40 hours per week, Monday - Friday, 8am-5pm
The UM Reviewer RN is accountable for performing initial, concurrent, or post service review activities; discharge care coordination; and assisting with efficiency and quality assurance of medical necessity reviews in alignment with Federal, State, Plan, and Accreditation standards. The UM reviewer serves as a liaison between providers/ facilities and Care Management Division. The essential job duties for this position are:
• Supports the Collaborative Care Management Model as a working partner with physicians, social workers, pharmacists and other professional staff.
• Accurately applies decision support criteria
• Demonstrates proficiency with caseload assignment and ability to manage complex cases effectively.
• Demonstrates an understanding of funding resources, services and clinical standards and outcomes.
• Demonstrates knowledge of case management standards of practice and processes including identification and assessment, planning, interventions and evaluation.
• Demonstrates a solid understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the effect on utilization and outcomes of the different methods of reimbursement.
• Demonstrates the ability to develop departmental interfaces with internal and external customers to provide exemplary service and achieve goals.
• Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to address
utilization/resource and progression of care issues. Assists in developing and implement an improvement plan to address issues.
• Implement discharge plan to prevent avoidable days or delays in discharge.
• Transition patient to next level of care in coordination with facility Discharge Planner.
• Identify and refer complex risk members to case management.
• Complete documentation timely, completely, and accurately in accordance with: (a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements.
• Identify documents and refer cases to the UM Team Leader for medical review when services do not meet medical necessity criteria, and/or appropriate level of care, and/or potential quality issues.
• Perform other duties as assigned.
The ideal candidate will possess the following qualifications:
• Associate's Degree Nursing required Or
• Bachelor's Degree Nursing preferred
• Master's Degree Nursing preferred
• 3 Years Utilization management experience in an acute or post-acute provider, health plan or other care company experience required and
• 2 Years experience in direct patient care as an RN, preferred acute care (ER, ICU, or Medical/ Surgical) required and
• 5 Years experience in Health Plan Utilization Review, Discharge Planning and Medical Case Management preferred.
• 2 years experience recent Medicaid Advantage experience highly preferred.
• Registered Nurse license upon hire required
• Experience and knowledge of Milliman Guidelines or similar clinical guidelines preferred
• Strong analytical and organizational skills
• Working knowledge and ability to apply professional standards of practice in work environment.
• Knowledge of specific regulatory, managed care requirements, and strong attention to detail.
• Working knowledge of computers and basic software applications used in job functions such as word processing, graphics, databases, spreadsheets, etc
Southwestern Health Resources Clinically Integrated Network (SWHR CIN) is a partner company of Texas Health. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health employee.