UM RN

Centers Plan for Healthy Living's goal is to create the ultimate healthcare experience that provides our members, their families, healthcare decision makers, and general caregivers with the guidance and plans they need for healthy living.

JOB SUMMARY:

The Utilization Management nurse works within a multidisciplinary team to help identify and manage members who are in need of additional care or support in their home to improve their quality of life. The Utilization Management nurse will assess and process all authorization requests to determine medical necessity to ensure all care services, member education, and preventative interventions are maintained.
 

PRIMARY RESPONSIBILITIES:

• Authorization of medically necessary services in coordination with the care management department. Review of care management documentation and outcomes evaluation to ensure member receives services and supports required to meet psychosocial, educational and health care needs
• Ensures that the services required for the plan of care is met in partnership with the person centric process which may include his/her significant other, primary caregiver, the primary and attending physicians, and various other providers and support involved in the member’s care.
• Provides utilization review for preauthorization, concurrent and discharge reviews and post service review
• Apply medical necessity guidelines based on appropriate criteria
• Utilizes knowledge of community resources and the member’s benefit structure
• Interacts with providers and facilities in a professional, respectful manner
• Recognizes quality of care issues and escalates the issues appropriately
• Have a knowledge of the Appeals and Grievances process
• Assists members with the coordination of services from various settings as appropriate
• Complies with all CPHL’s standards for documentation
• Participates in case rounds as a member of the Integrated Care Team
• Participates in on call scheduling
• Participates in other meetings as requested
• Participates in quality improvement initiatives
• Other duties as assigned    

EDUCATION AND EXPERIENCE:

Type of Experience

Required:

• Active and unrestricted NYS RN license
• Minimum 2 years utilization management experience
• Strong written and verbal communication skills
• Ability to travel within assigned area

Preferred:

• Bachelor of Science in Nursing
• CCM certification
• Knowledge of Milliman or InterQual criteria

Preferred:

• Experience working within a managed care environment

Specific Technical Skills

Preferred: Computer proficiency

SCOPE INFORMATION

# Direct Reports: 0

PHYSICAL REQUIREMENTS:

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification. They should not be construed as an exhaustive list of all responsibilities, duties and skills required

Centers Plan For Healthy Living is committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our employees and our business. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law and will not be denied employment.