utilization management rn

Centene

<div>You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. 
Position Purpose: Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team.<ul><li>
Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards</li>
<li>Collaborates with utilization management team to resolve complex care member issues</li>
<li>Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management</li>
<li>Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management</li>
<li>Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers</li>
<li>Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures</li>
<li>Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services</li>
<li>Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones</li>
<li>Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards</li>
<li>Assists with onboarding, hiring, and training utilization management team members</li>
<li>Leads and champions change within scope of responsibility</li><li>
Performs other duties as assigned</li>
<li>Complies with all policies and standards</li></ul>
Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience. 
 
Knowledge of utilization management principles preferred. 
 
License/Certification:<ul><li>
RN - Registered Nurse - State Licensure and/or Compact State Licensure required</li><li>
CA RN LICENSE REQUIRED</li></ul>
Pay Range: $75,300.00 - $135,400.00 per year
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. 
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act</div>

Supervisor, Utilization Management (RN)

Humana

<div>
 
 Become a part of our caring community
 
 
 
 The Utilization Management Registered Nurse uses clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations. You will report to the Manager of Utilization Management and serve as a member of the One Home/Home Solutions Utilization Management team. This team manages post-acute care services. These services include Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME). The team's goal is to ensure members receive the appropriate level of care in the most appropriate setting.
 
 
 
 As a Utilization Management Registered Nurse
 
 
 
 <ul>
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 You will use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations.
 </li>
 <li>
 Using established medical criteria, you will make determinations based on information provided by the attending physician and other care providers
 </li>
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 You will complete request determinations within established processing time frames. (i.e. 10 reviews per day?)
 </li>
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 You will communicate with providers, members, or other parties to facilitate care and treatment.
 </li>
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 You will help deliver coordinated care for our members
 </li>
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 You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.
 
 
 </li>
 </ul>
 
 Required Qualifications
 
 
 
 
 Use your skills to make an impact
 
 
 
 <ul>
 <li>
 Must hold Compact Registered Nurse (RN) license in your state of residence
 </li>
 <li>
 Greater than one year of clinical experience as a RN in a hospital, SNF, Home Health, or acute care setting.
 </li>
 <li>
 Must be passionate about contributing to an organization focused on improving consumer experiences
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Previous experience in utilization management/utilization review for a health plan or acute care setting
 </li>
 <li>
 Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual.
 </li>
 <li>
 Experience working in a fully remote, metrics-focused role
 </li>
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 Experience as an MDS Coordinator or discharge planner in an acute care setting
 </li>
 <li>
 Experience as an RN for a Medicare Certified Home Health agency
 </li>
 <li>
 Health Plan or Medicare / Medicaid Experience
 </li>
 <li>
 Call center or triage experience
 </li>
 <li>
 BSN or bachelor's degree in a related field
 
 
 </li>
 </ul>
 Additional Information
 
 
 
 Work-at-Home Information
 
 
 
 To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
 
 
 <ul>
 <li>
 At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
 </li>
 <li>
 Satellite, cellular and microwave connection can be used only if approved by leadership.
 </li>
 <li>
 Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
 </li>
 <li>
 Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
 </li>
 <li>
 Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
 
 
 </li>
 </ul>
 Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
 
 
 
 Scheduled Weekly Hours
 
 
 
 40
 
 
 
 Pay Range
 
 
 
 The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
 
 
 $71,100 - $97,800 per year
 
 
 This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
 
 
 
 Description Of Benefits
 
 
 
 Humana, Inc. and its affiliated subsidiaries (collectively, &ldquo;Humana&rdquo;) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
 
 
 
 About Us
 
 
 
 About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health &ndash; delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
 
 
 
 Equal Opportunity Employer
 
 
 
 It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
</div>

Utilization Management Registered Nurse

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