Group Health Cooperative of South Central Wisconsin. BETTER TOGETHER

This position is a remote position after initial onboarding and training period. Candidates must reside in the state of Wisconsin.

Using a collaborative process, the Care Management (CM) Utilization Management Nurse (RN) will review, plan, implement, monitor, and evaluate the options and services required to meet an individual's health needs, using communication and available resources to promote quality, and cost-effective outcomes. He/she helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner while maintaining quality of care.

The CM Utilization Management Nurse (RN) is responsible for evaluating the medical appropriateness, quality, and cost effectiveness of proposed services in accordance with established criteria. This review activity may be conducted prospectively, concurrently, or retrospectively and in collaboration with patients, practitioners, and other professionals. The incumbent plays an integral role in working with the RN and Social Work Case Managers on an ongoing basis and providing support. The incumbent provides support and is a resource for the Care Management Associates and other staff. Work is performed under the general direction, guidance, and supervision of the Care Management Department Manager.

The Utilization Management Nurse knows and abides by all Group Health Cooperative of South Central Wisconsin (GHC-SCW) organizational and departmental policies, sets personal standards and strives for high quality work in completing assignments, performs job duties in a timely manner, and represents the organization in a positive manner.The incumbent understands our Mission, Vision and Common Values (stated below) and is committed to promote these values in behavior and attitude.

Our Mission Statement: We partner with members and the communities we serve to maximize health and well-being.

Our Vision: As a local, not-for-profit, member-owned Cooperative, we are the most trusted resource for lifelong health and well-being in the communities we serve.

Our Values:

• We are a not-for-profit Cooperative
• We are member-centered
• We are equitable and inclusive
• We are quality-driven
• We are innovative
• We are community involved

GHC-SCW is committed to fostering a caring and compassionate environment while ensuring that individual differences are valued. GHC-SCW is a quality driven cooperative built on collaboration, community involvement, innovation, and belonging. It is essential that all employees, members, and patients feel secure and welcome, that the opinions and contributions of all individuals are respected and that all voices are heard.

We believe:

Healthcare is a human right.

In treating all people with dignity and respect.

There is strength in diversity.

Equity celebrates our humanity.

We are better together.

1. 1. Graduation from NLN accredited school of Nursing. Bachelor's degree is preferred.
   2. Valid current license to practice in the State of Wisconsin as a Registered Nurse is required.
   3. Minimum of one (1) year experience in: Utilization Review, Insurance/Managed Care, Home Health and/or diversified clinical experience, two (2) years preferred.
   4. Knowledge of utilization principles, methods, and techniques with experience in primary and/or acute care management. Ability to follow established criteria, policies, and procedures utilized in medical reviews.
   5. Ability to keep abreast of legal and regulatory changes affecting the delivery of care.
   6. Excellent oral and written communication skills required. Ability to communicate effectively in person, in groups, and on the telephone.
   7. Ability to be culturally sensitive and to work with a diverse patient population.
   8. Knowledge of and ability to use computer based applications such as MS Office, (word processing, email, calendar). Knowledge of and/or ability to learn and effectively use electronic medical and insurance record systems. Experience with EPIC systems is desirable but not required.
   9. Ability to maintain patient and organizational confidentiality required. Knowledge of or ability to learn HIPAA requirements.
   10. Knowledge of medical records and appropriate documentation requirements.
   11. Ability to apply clinical criteria to analyze requests.
   12. Self-motivation and self-direction required; capable of working independently with limited direct supervision.
   13. Excellent customer service skills. Ability to work effectively with all levels of staff, practitioners, internal departments, external parties and members.
   14. Strong organizational skills. Ability to pay attention to details.
   15. Ability to function as a team player.
   16. Possession of a valid Wisconsin Driver License with good driving record. Employee must be able to provide own transportation to various worksites.
   17. Ability to sit, stand, walk, and drive on a regular basis required.

Group Health Cooperative of South Central Wisconsin is proud to be an equal opportunity employer. GHC-SCW considers candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

• Administration - 1265 John Q. Hammons Drive, 1265 John Q. Hammons Dr. , Madison, Wisconsin, United States of America