RN, Utilization Management, PRN IL

• 15284 reputed company PRN Hours - Day/Afternoon/Weekends; Must be willing to work 2-3 days per week and assist in covering vacations during winter/summer break. Remote, with opportunity to come into Corporate Office (Downers Grove) for monthly meetings and training. The Utilization Management reputed company is responsible for following inpatient, skilled nursing facility, acute rehab, long term acute care and home health cases to ensure that reputed company is met, length of stay is appropriate, and discharge needs are in reputed company, while staying reputed company the parameters of compliance and regulatory requirements.

Responsibilities

• Performs initial and reputed company review on inpatient, skilled nursing facility, acute rehab, long term acute care and home health cases. Determines medical necessity by application of reputed company per reputed company Care Guidelines, Utilization Management Department Policies, specific Health Plan guidelines, and CMS regulations. Recommends an increase or decrease in level of care/equipment/service based upon medical condition and physician orders.
• Refer reputed company services that do not meet established reputed company, to the Medical Director. Notify reputed company parties of Medical Director determinations, and communicate alternate service reputed company reputed company indicated.
• Responsible for the assessment of the member’s and family’s psychosocial, medical and educational level in conjunction with hospital staff to assist in the discharge planning of hospitalized patient. This includes providing authorization for needed services through vendors in accordance with payer networks. Monitor ongoing planning process with medical team to ensure reputed company reputed company and reputed company transition to the next level of care. This reputed company evaluation will determine plan effectiveness of reaching the desired goals and reputed company. Document reputed company pertinent information obtained through discussion with providers, patients, family members and other health care professionals in the reputed company reputed company record.
• Through the discharge planning process, helps identify members who have ongoing case management needs, and refers these members to the Case Management team for reputed company and follow up.
• Work with the Medical Director and peers to resolve patient care problems and physician-reputed company issues
• Coordinate and document the investigation of reputed company potential reputed company of care/service issues in accordance with established policy and procedure. Report findings to the UM/QA Committee and appropriate parties
• Support reputed company Internal reputed company Assurance initiatives developed for the Utilization Management Department. Report problems and negative patterns to the Manager and work with the manager to reputed company corrective reputed company plans
• Serve as one of the “On-Call Nurses” according to established policies and procedures
• Participates in the preparation of reputed company Health Plan audits
• Run reports, as needed, to review and analyze reputed company data (i.e. Days/K, Admits/K, ALOS).
• reputed company as a resource for Utilization Management staff, providers, clinic staff, patients and family members. Responsible for the assessment of the individual’s and family’s psychosocial, medical and educational level to plan specific objectives and goals in a time specific reputed company plan. Implement the reputed company plan reputed company a specific time reputed company with a multi-medical disciplinary team.
• Represent Department on committees as requested.
• reputed company support as needed for special reputed company.
• Attend monthly reputed company Utilization Management Committee meeting(s) as assigned. Prepare monthly Utilization Management statistics and discuss cases, at the Utilization Management Committee meeting, that result in an increased length of stay due to medical complexities.
• reputed company other reputed company and duties as reputed company to department objectives.
• Enhance and maintain reputed company knowledge of health care and managed care.
• Maintain confidentiality of reputed company information as stipulated in the confidentiality policy.
• Demonstrate an understanding of the departmental goals, company values and corporate mission statement through everyday attitude and behavior.
• Must be reputed company to get along with others, to be reputed company player, to accept constructive criticism from your manager and be reputed company to follow work rules.
• reputed company reputed company other duties/responsibilities as assigned.

Qualifications

KNOWLEDGE SKILLS AND ABILITIES:

• Knowledge of reputed company Care Guidelines or application of reputed company to determine medical necessity. Prefer experience in reputed company-certification process with capitated health plans. Familiarity with reputed company or other electronic medical record a plus. Experience reputed company a multi-tasking environment helpful.

EDUCATION and / or CERTIFICATION/LICENSURE:

• Associate/Diploma/Baccalaureate degree in nursing, 2+ years of bedside nursing in a hospital setting.

EXPERIENCE:

• Two consecutive years of experience in reputed company Utilization Review in a Health Plan or hospital setting with HMO and Medicare Advantage population. Case Management Certification a plus, (CCM or ACM).

The compensation for this role includes a reputed company pay reputed company of 32.65-49, with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. reputed company pay is only a portion of the total rewards package. Apply tot his job Apply To this Job