What are the responsibilities and job description for the Utilization Management - Registered Nurse - (full-time/remote/hybrid) position at Prairie States Enterprises, Inc.?
UTILIZATION MANAGEMENT - REGISTERED NURSE (FULL-TIME / REMOTE / HYBRID)
This is a full-time position with a hybrid remote work arrangement in our Sheboygan, WI location. No weekends, holidays or on-call rotations. Ideal candidate will work in Wisconsin.
Prairie States Enterprises, Inc. is a third party administrator, a benefits industry leader, and a trusted advisor to self-insured companies and their employees. We provide a complete range of medical benefit management services, all performed in-house, and to exacting standards of excellence.
JOB SUMMARY
The Utilization Management RN is responsible for the utilization management/review of claimants from PSE’s book of business.
SUMMARY OF ESSENTIAL JOB FUNCTIONS
This is a full-time position with a hybrid remote work arrangement in our Sheboygan, WI location. No weekends, holidays or on-call rotations. Ideal candidate will work in Wisconsin.
Prairie States Enterprises, Inc. is a third party administrator, a benefits industry leader, and a trusted advisor to self-insured companies and their employees. We provide a complete range of medical benefit management services, all performed in-house, and to exacting standards of excellence.
JOB SUMMARY
The Utilization Management RN is responsible for the utilization management/review of claimants from PSE’s book of business.
SUMMARY OF ESSENTIAL JOB FUNCTIONS
- Claim reviews: Pre-Claim, Concurrent Claim, and Post-Claim Reviews (Retro Reviews) as identified by claims analyst, bill audit staff, or Health Management
- Responsible for UM-RN function of designated groups.
- Reviews and contacts Clinical staff at the Provider for medical information to ensure the completeness of the medical record.
- Researches Plan language in the Employer Benefit Plan Document, and makes a clinical determination of coverage or no coverage.
- Coordinates the sending of cases out for medical review if required.
- Responsible for the authorization of services or denial of services based on the Employer Benefit Plan Document. Subsequently also handles all appeals.
- Assists with maintaining Quick Reference Guide for designated groups
- Stop Loss Reporting:
- Notify Case Manager of potential need for CM as appropriate
- Vacation and Overflow coverage for standard Pre-certification and Utilization Management staff (does not cover FiveStar)
- Assists with writing and updating Policies and or Procedures related to the UM function
- Other duties as assigned
POSITION REQUIREMENTS
- Adherence to the Scope of Standards of Practice for RNs
- Perform Utilization Management according to PSE standards and national standards for utilization management
- Adherence and application of HIPAA regulations
- Experience in utilization review, concurrent review and /or discharge planning
- Ability to work collaboratively with the Health Management Team and the Claims Processing Team
- Become familiar with the Prairie States Enterprises’ Book of Business Health Care Plans
- Become familiar with the Appeals Process for disputed claims
- Become proficient in the use of applicable software systems including Acuity and the Eldorado® Claims System
- Must be able to carry on conversations with medical providers, and members to facilitate good understanding by all parties
- Effective communication skills including oral, nonverbal, and written
- Strong organizational skills
- Must have a basic computer skills and ability to learn new computer programs
- Cross-train to all aspects of Health Management; Perform other tasks as required by the Health Management
POSITION QUALIFICATIONS
- BSN Required; RN current licensure in good standing
- Minimum of 5 years of clinical experience
- Past UM or CM experience in clinical or hospital setting desirable
- Strong competence in the use and understanding of the MCG guidelines for medical necessity.
- Strong competence with patient care management systems
- Proficient Computer Skills: Word, Excel, Microsoft Outlook, keyboarding and data entry
REQUIRED COMPETENCIES
- Change Management – Accepts, supports, and executes assignments in conditions of change which support attaining department goals.
- Effective Communication – Demonstrates effective and responsive communications following the appropriate reporting structure.
- Accountability/Results – Achieves and/or exceeds result based goals that were specific, measurable, and timely.
- Teamwork – Demonstrates teamwork behaviors and makes positive contributions and which support the achievement of department goals.
- Customer Satisfaction – Dedicated to the PSE service model and meets or exceeds PSE customer satisfaction expectations in providing exemplary service.
- Professional Growth – Takes ownership of one’s professional growth within one’s current position and to advancement at PSE.
PHYSICAL DEMANDS / WORK ENVIRONMENT
This is sedentary position which requires the individual to sit for long periods of time and the proper positioning/posturing for extensive viewing of computer screens and computer related work is required. It is encouraged that individuals intermix this sedentary time with periodic movement within one’s office space and/or to other office areas to counteract the sedentary nature of this position.
To the selected candidate, we offer:
Competitive compensation based on experience and a comprehensive benefit package provided to include Medical, Dental, Vision, Life, STD/LTD, FSA, Paid Time Off, personal days, 401k with match, wellness and exercise membership and more. Click HERE to view our full-time benefits flyer.
Opportunity for meaningful career growth within a results-driven company and our company culture is one of ambition, integrity, empowerment, teamwork and a passion for personal and company success.
If this sounds like you and you’re seeking career growth with an exciting new career path in overseeing the quality of health care for our clients and their members, please send your cover letter and resume following the instructions for this site.
Prairie States Enterprises
Equal Opportunity Employer
If this sounds like you and you’re seeking career growth with an exciting new career path in overseeing the quality of health care for our clients and their members, please send your cover letter and resume following the instructions for this site.
Prairie States Enterprises
Equal Opportunity Employer