Job Description: Utilization Management Nurse
Summary: The Utilization Management Nurse works with the Managed Care Organization (MCO) team, primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing members with the right care at the right place at the right time. The role involves daily review and evaluation of members requiring hospitalization and/or procedures, providing prior authorizations and/or concurrent reviews. The Utilization Management Nurse assesses services to ensure optimum outcomes, cost-effectiveness, and compliance with all state and federal regulations and guidelines.
- Conducts concurrent review and prior authorizations (as needed) according to MCO policy for MCO members as part of the Utilization Management team.
- Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
- Collaborates with various departments, including Behavioral Health and Long Term Care, to enhance the continuity of care for MCO members.
- Maintains department productivity and quality measures.
- Attends regular staff meetings and assists in mentoring new team members.
- Completes assigned work plan objectives and projects on a timely basis.
- Maintains professional relationships with the provider community and internal and external customers.
- Consults with and refers cases to MCO medical directors regularly, as necessary.
- Complies with required workplace safety standards.
- Demonstrated ability to communicate effectively, problem-solve, and collaborate with team members.
- Excellent organizational skills with the ability to manage multiple priorities.
- Ability to work independently and handle multiple projects simultaneously.
- In-depth knowledge of applicable state and federal regulations.
- Familiarity with Interqual and other references for length of stay and medical necessity determinations.
- Experience with the National Committee for Quality Assurance (NCQA).
- Proficiency in computer applications, including Microsoft Office Products.
- Excellent verbal and written communication skills.
- Ability to abide by MCO's policies.
- Strong commitment to maintaining attendance to support required quality and quantity of work.
- Maintains confidentiality and complies with Health Insurance Portability and Accountability Act (HIPAA).
- Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers, and customers.
Required Education and Experience:
- Completion of an accredited Registered Nursing program. (A combination of experience and education will be considered in lieu of a Registered Nursing degree).
- Minimum 2-4 years of clinical practice, preferably in hospital nursing, utilization management, and/or case management.
- Active, unrestricted Nebraska State Registered Nursing license (RN) in good standing.
- Monday to Friday, 8:00 AM to 5:00 PM CST
The Utilization Management Nurse plays a crucial role in ensuring that MCO members receive high-quality care while managing healthcare costs effectively and complying with all regulatory requirements. This position offers the opportunity to work as part of a dynamic team dedicated to improving patient outcomes and healthcare delivery within the managed care organization.