Utilization Management Nurse

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.