Utilization Review Nurse
: Job Details :

American Health Plans Franklin, TN 37067, USA You must reside in one of the following states for this position:AL, AR, AZ, FL, GA, IA, ID, IL, IN, KS, KY, LA, MI, MO, MS, NC, NY, OH, OK, PA, SC, TN, TX, UT, WIAmerican Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc., owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Iowa, Idaho, Louisiana, and Indiana with planned expansion into other states in 2025. For more information, visit .If you would like to be part of a collaborative, supportive, and caring team, we look forward to receiving your application!Benefits and Perks include:Affordable Medical/Dental/Vision insurance optionsGenerous paid time-off program and paid holidays for full-time staffTeleDoc 24/7/365 access to doctorsOptional short- and long-term disability plansEmployee Assistance Plan (EAP)401K retirement accounts with company matchEmployee Referral Bonus ProgramJOB SUMMARY:The Utilization Review Nurse is to assess the medical necessity and quality of healthcare services by conducting pre-service, concurrent, and retrospective utilization management reviews. The primary role of the Utilization Management (UM) Nurse is to provide clinical support to the Clinical Services Department and Medical Director to assure that members receive all appropriate medical services in compliance with medical and regulatory guidelines.ESSENTIAL JOB DUTIES:To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.Assess the medical necessity, quality of care, level of care, and appropriateness of healthcare services for plan membersIdentify placement settings that offer the lowest level of restriction and the greatest level of autonomy for the members based upon medical necessityConduct outreach to requesting providers which can include specialty physicians, ancillary providers, and institutions to gather the appropriate/necessary clinical dataApply clinical review criteria, guidelines, and screens in determining the medical necessity of healthcare services against the clinical data providedCertify cases that meet clinical review criteria, guidelines, and/or screensConsult with physicians when reviews do not meet clinical review criteria, guidelines, and screensRefer cases to other professionals internally, including case management and medical consultation when indicatedAdhere to accreditation, contractual, and regulatory timeframes in performing all utilization management review processesEnsure that the Director of Medical Management or designee is made aware of any potential risk management issues in a timely mannerOther duties as assignedJOB REQUIREMENTS:Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees, and facilityEncourage an atmosphere of optimism, warmth, and interest in patients' personal and healthcare needsDevelop and maintain collaborative relationships with providers and educate on levels of careEnsure the integrity and high quality of utilization management servicesSelf-motivatedAbility to work independently and as part of a teamAble to work congenially with a wide variety of individualsMaintain the highest level of confidentiality and professionalism at all timesStrong oral and written communication skills, including active listeningProficient in navigating through multiple computer applicationsCritical thinking and decision-making skillsSuccessful completion of required trainingREQUIRED QUALIFICATIONS:At least 1 year experience in utilization management with a health plan or hospital-based UM department with use of Interqual or MCGPrefer clinical experienceBroad knowledge of Medicare regulations and guidanceTrained in clinical certification, utilization management, URAC, and NCQA principles, policies, and proceduresStrong knowledge of medical terminology and CPT, ICD-10, and HCPCS codesProven ability to problem-solve and make solid decisionsCurrent Certified Case Manager (CCM) credential is a plusCurrent, active, and unrestricted Registered Nurse (RN) licenseEQUAL OPPORTUNITY EMPLOYERThis Organization is an equal opportunity employer. We do not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. This Organization will make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. A key part of this policy is to provide equal employment opportunity regarding all terms and conditions of employment and in all aspects of a person's relationship with the Organization including recruitment, hiring, promotions, upgrading positions, conditions of employment, compensation, training, benefits, transfers, discipline, and termination of employment.#J-18808-Ljbffr