What are the responsibilities and job description for the Utilization Management Nurse (RN) - Case Management - Day position at SimplyApply?
Schedule
Full Time : 40 Hours / Week
Hours : Monday - Friday 8am - 4 : 30pm
Weekend Rotation Required
This is a remote position that requires candidates to be located within 50 miles of WellSpan's geographic footprint in South Central Pennsylvania or in Northern Maryland. Occasional travel is required within WellSpan's geographic footprint.
General Summary
Performs a variety of reviews and applies utilization and case management techniques to determine the most efficient use of resources to support the provision of appropriate, cost effective and quality health care. Provides leadership in the integration of utilization management principles throughout the System. Responsible for screening patients for care management programs, including bundles and complex care management.
Duties and Responsibilities
Essential Functions :
Performs initial reviews for medical necessity and appropriateness of setting for the assigned case load.
Conducts concurrent reviews to ensure medical necessity for continued hospitalization and initiates problem-solving techniques as needed to prevent over and / or under utilization. Refer cases to Medical Director that require additional expertise.
Liaisons between third party payors and the treatment team regarding the identified treatment plan in accordance with contractual guidelines or System policy.
Assists the patient care team with the identification and coordination of alternative treatment settings which will provide appropriate care, maintain quality of care and reduce cost.
Identifies conditions which require case management across the continuum. Collaborates with the members of the patient care team to identify interdisciplinary needs. Refer to appropriate care management or disease management program.
Assists with the collection and analysis of utilization patterns and denied cases.
Brings known or suspected problems of under-, over-, or inappropriate utilization of resources to the attention of the appropriate manager(s).
Common Expectations :
Prepares and maintains appropriate documentation as required.
Maintains established policies and procedures, objectives, quality assessment and safety standards.
Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
Prepares and presents utilization data analysis as required.
Develops and initiates educational programs regarding utilization management principles.
Attends meetings as required.
WellSpan Health's vision is to reimagine healthcare through the delivery of comprehensive, equitable health and wellness solutions throughout our continuum of care. As an integrated delivery system focused on leading in value-based care, we encompass more than 2,300 employed providers, 250 locations, nine award-winning hospitals, home care and a behavioral health organization serving central Pennsylvania and northern Maryland. Our high-performing Medicare Accountable Care Organization (ACO) is the region's largest and one of the best in the nation. With a team 23,000 strong, WellSpan experts provide a range of services, from wellness and employer services solutions to advanced care for complex medical and behavioral conditions. Our clinically integrated network of 3,000 aligned physicians and advanced practice providers is dedicated to providing the highest quality and safety, inspiring our patients and communities to be their healthiest.
Qualifications
Minimum Education :
Associates Degree Required
Work Experience :
3 years Relevant experience. Required
Experience in utilization management, case management, or clinical nursing specialty. Preferred and
Working in Human Resources with specific responsibility for leave of absence administration or management. Preferred
Licenses :
Licensed Registered Nurse Upon Hire Required or
Registered Nurse Multi State License Upon Hire Required
Benefits Offered ( click here for more details ) :
Comprehensive health benefits
Flexible spending and health savings accounts
Retirement savings plan
Paid time off (PTO)
Short-term disability
Education assistance
Financial education and support, including DailyPay
Wellness and Wellbeing programs
Caregiver support via Wellthy
Childcare referral service via Wellthy
SimplyApply
