utilization review nurse

MagnaCare

<div>
 
 Primary Responsibilities
 
 
 
 <ul>
 <li>
 Perform prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures.
 </li>
 <li>
 Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
 </li>
 <li>
 Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning.
 </li>
 <li>
 Provides referrals to Case management, Disease Management, Appeals &amp; Grievances, and Quality Departments as needed.
 </li>
 <li>
 Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
 </li>
 <li>
 Triages and prioritizes cases and other assigned duties to meet required turnaround times.
 </li>
 <li>
 Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations. Communications determinations to providers and/or members in compliance with regulatory and accreditation requirements.
 </li>
 <li>
 Experience with Complex Medical case reviews including but not limited to: Oncology, Clinical Trials, High Cost Medical Pharmacy and Transplants.
 </li>
 <li>
 Act as a resource for complex case discussions for all staff.
 
 
 </li>
 </ul>
 
 Essential Qualifications
 
 
 
 <ul>
 <li>
 Current licensed Registered Nurse (RN) with state licensure. Must retain active licensure throughout employment.
 </li>
 <li>
 Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
 </li>
 <li>
 Must be able to work independently.
 </li>
 <li>
 Adaptive to a high pace and changing environment.
 </li>
 <li>
 Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
 </li>
 <li>
 Working knowledge of URAC and NCQA.
 </li>
 <li>
 3+ years&rsquo; experience in a UM team within managed care setting.
 </li>
 <li>
 5+ years experience in clinical nurse setting preferred.
 </li>
 <li>
 TPA Experience preferred.
 
 
 </li>
 </ul>
 
 About
 
 
 
 At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you&rsquo;ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you&rsquo;ll be encouraged to bring your authentic self to work with all of your unique abilities.
 
 
 Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today&rsquo;s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today&rsquo;s challenges into tomorrow&rsquo;s solutions.
 
 
 Come be a part of the Brightest Ideas in Healthcare&trade;.
 
 
 
 Company Mission
 
 
 
 Transform the health plan experience &ndash; how health care is accessed and delivered &ndash; by bringing outstanding products and services to our partners.
 
 
 
 Company Vision
 
 
 
 Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
 
 
 
 DEI Purpose Statement
 
 
 
 At BHPS, we encourage all team members to bring your authentic selves to work with all of your unique abilities. We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace. We are building, nurturing and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level.
 
 
 <ul>
 <li>
 We are an Equal Opportunity Employer
 </li>
 </ul>
</div>

Utilization Review Nurse, Complex Care

Brighton Health Plan Solutions

<div>
 
 About The Role
 
 
 
 BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member&rsquo;s benefit coverage while working remotely.
 
 
 
 Primary Responsibilities
 
 
 
 <ul>
 <li>
 Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures
 </li>
 <li>
 Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments
 </li>
 <li>
 Collaborates with healthcare partners to ensure timely review of services and care
 </li>
 <li>
 Provides referrals to Case management, Disease Management, Appeals &amp; Grievances, and Quality Departments as needed
 </li>
 <li>
 Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
 </li>
 <li>
 Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate
 </li>
 <li>
 Triages and prioritizes cases and other assigned duties to meet required turnaround times
 </li>
 <li>
 Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations
 </li>
 <li>
 Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements
 </li>
 <li>
 Duties as assigned
 
 
 </li>
 </ul>
 
 Essential Qualifications
 
 
 
 <ul>
 <li>
 Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment
 </li>
 <li>
 Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
 </li>
 <li>
 Must be able to work independently
 </li>
 <li>
 Must be detail oriented and have strong organizational and time management skills
 </li>
 <li>
 Adaptive to a high pace and changing environment- flexibility in assignment
 </li>
 <li>
 Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review
 </li>
 <li>
 Proficient in MCG and CMS criteria sets
 </li>
 <li>
 Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred
 </li>
 <li>
 Working knowledge of URAC and NCQA
 </li>
 <li>
 2+ years&rsquo; experience in a UM team within managed care setting
 </li>
 <li>
 3+ years&rsquo; experience in clinical nurse setting preferred
 </li>
 <li>
 TPA Experience preferred
 
 
 </li>
 </ul>
 
 About
 
 
 
 At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you&rsquo;ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you&rsquo;ll be encouraged to bring your authentic self to work with all of your unique abilities.
 
 
 Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today&rsquo;s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today&rsquo;s challenges into tomorrow&rsquo;s solutions.
 
 
 Come be a part of the Brightest Ideas in Healthcare&trade;.
 
 
 
 Company Mission
 
 
 
 Transform the health plan experience &ndash; how health care is accessed and delivered &ndash; by bringing outstanding products and services to our partners.
 
 
 
 Company Vision
 
 
 
 Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
 
 
 Powered by JazzHR
 
 
 DLcZRrpbP4
</div>

Utilization Management Nurse

Matrix Providers

Matrix Providers is hiring a Registered Nurse - Utilization Management to join our team of talented professionals who provide health care services to our Military Service Members and their families in at Buckley AFB, Aurora, CO. Employment Status: Full Time Compensation: $36.57 - $51.96 per hour Benefits: Competitive financial package with a comprehensive insurance package including health, dental, vision, and life coverage. Accrued Paid Time Off (PTO) Paid Holidays (Outlined in Handbook) 401(k) Plan Minimum Requirements Registered Nurse (RN) Utilization Management: Degree/Education: Bachelor&rsquo;s degree in nursing. Certifications: Basic Life Support Certified/certification eligible in relevant specialty such as: Certified Managed Care Nurse through the American Board of Managed Care Nurses; Certification in Health Care Quality and Management (HCQM) through American Board of Quality Assurance and Utilization Review Physicians (ABQARP) Certified Informatics Nursing, Ambulatory Care Nursing, Medical-Surgical Nursing or Nursing Case Management through the American Nurses Credentialing Center Utilization Management Accreditation through National Committee for Quality Assurance (NCQA) are desired. Experience: A minimum of 36 months total nursing experience in a direct patient care clinical setting. Must have utilization management, utilization review or case management experience for 12 recent consecutive months within the last 12 months. Licensure/Registration: Current, full, active, and unrestricted license to practice as a Registered Nurse. Overview: Serve as a key member of the Utilization Management team, providing comprehensive support to TRICARE beneficiaries. Function independently to ensure appropriate, cost-effective healthcare delivery within TRICARE and Military Health System (MHS) guidelines. Key Responsibilities: Manage a robust Utilization Management program, conducting reviews (prospective, concurrent, retrospective) to ensure proper use of patient care services. Analyze trends, identify inefficiencies, and recommend process improvements to optimize patient care at appropriate levels. Coordinate with military and civilian providers to ensure services meet medical necessity, cost-effectiveness, and TRICARE standards. Serve as a resource for primary care managers, interpreting guidelines, monitoring referrals, and optimizing MTF and civilian healthcare services. Identify and address access/utilization challenges, including enrollment, procedures, inpatient admissions, claims, and grievances. Conduct systematic monitoring and evaluation of utilization metrics, identifying areas for improvement and reporting findings. Provide training to healthcare providers on referral practices for quality and cost-effective care. Qualifications: Advanced knowledge of TRICARE, MHS policies, and referral management systems. Strong analytical skills with the ability to interpret data and recommend solutions. Experience with Electronic Health Records (MHS Genesis preferred). Interpersonal skills to collaborate effectively with diverse teams and stakeholders. Desired Skills: Familiarity with government regulations, healthcare financing, and quality/risk management. Proficiency in office automation software and DHA-approved documentation systems. This role supports healthcare excellence by optimizing resources, improving care quality, and ensuring compliance with TRICARE and DHA standards. We support our employees with an accessible dedicated representative to assist you throughout the duration of your contract. We firmly believe that a healthy work/life balance enables you to perform at your best. Our mission is to serve America&rsquo;s military family by aligning exceptional healthcare workers like you with rewarding career opportunities. Come home to Matrix. #INDKK

Registered Nurse - Utilization Management

Broadway Ventures

<div><div><div><div>At Broadway Ventures, we transform challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), we empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth. Built on integrity, collaboration, and excellence, we're more than a service provider&mdash;we're your trusted partner in innovation.
</div>
</div></div>Max Salary: W-2 ($65,000/$31.25)

Job Type: Full-time (40 hours/week) 
Schedule: Monday&ndash;Friday, 8:00 AM &ndash; 5:00 PM EST (core hours) 
Location: Remote (U.S. &ndash; Work from home) 
Remote Work Requirements: High-speed internet (non-satellite) and a private, lockable home office 
Equipment: You will be provided with all necessary equipment to perform your job effectively, including but not limited to a desktop computer, dual monitors, a headset, an ethernet cable, and additional accessories as needed.

About the Role:

We are seeking a dedicated Registered Nurse (RN) to join our Medical Review team. This role involves conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines. The ideal candidate will use their clinical expertise to assess medical necessity, appropriateness, and reimbursement eligibility while documenting decisions in accordance with regulatory and organizational requirements.

Key Responsibilities:
<ul>
<li>Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.</li>
<li>Assess payment determinations using clinical information and established guidelines.</li>
<li>Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.</li>
<li>Provide clear, well-documented rationales for service approvals or denials.</li>
<li>Educate internal and external teams on medical review processes, coverage determinations, and coding requirements.</li>
<li>Support quality control activities to meet corporate and team objectives.</li>
<li>Assist with special projects and additional responsibilities as assigned.</li>
</ul>
Minimum Qualifications:

Licensure:
<ul>
<li>Active, unrestricted RN license in the U.S. and in the state of hire 
OR</li>
<li>Active compact multistate RN license (as defined by the Nurse Licensure Compact).</li>
</ul>
Education:
<ul>
<li>Associate Degree in Nursing 
OR</li>
<li>Graduate of an accredited School of Nursing.</li>
</ul>
Experience:
<ul>
<li>Two years of clinical experience plus at least two years in one of the following:</li>
<li><ul><li>Inpatient/Outpatient settings (i.e. medical-surgical, rehabilitation, SNF, etc..)</li>
<li>Utilization/Medical Review</li>
<li>Quality Assurance</li>
</ul></li>
</ul>Skills &amp; Competencies:
<ul>
<li>Strong clinical background in managed care and/or inpatient/outpatient</li>
</ul>
 settings.
<ul>
<li>Ability to interpret and apply medical review criteria and clinical guidelines.</li>
<li>Proficiency in Microsoft Office and word processing software.</li>
<li>Strong analytical, organizational, and decision-making skills.</li>
<li>Ability to work independently while managing priorities effectively.</li>
<li>Excellent customer service, communication, and critical thinking skills.</li>
<li>Ability to handle confidential information with discretion.</li>
</ul>
Preferred Qualifications:
<ul>
<li>Three years of clinical nursing experience in Inpatient/Outpatient settings, Utilization Review, Medical Review, or Quality Assurance (strongly preferred).</li>
<li>Proficiency in using multiple screens and software programs simultaneously.</li>
<li>Training and experience in ICD coding.</li></ul> 

<div>
What to Expect Next:

After submitting your application, our recruiting team will review your qualifications. This may include a brief telephone interview or email communication to verify resume details and discuss compensation expectations. Interviews will be conducted with the most qualified candidates. Broadway Ventures conducts background checks and drug testing prior to the start of employment. Some positions may also require fingerprinting.

Broadway Ventures is an equal opportunity employer and a VEVRAA federal contractor. We do not discriminate against applicants or employees on the basis of race, color, religion, sex, national origin, age, disability, protected veteran status, or any other status protected by applicable law.

Reasonable accommodations are available for applicants with disabilities. Broadway Ventures utilizes the OFCCP-approved Voluntary Self-Identification of Disability Form (CC-305).</div></div>

Remote RN – Medical Claims Reviewer

Connecticut Children's

<div>
 
 Job Description
 
 
 
 
 Applicants must be residents of Connecticut, Massachusetts, or New York to be considered for this position.
 
 
 
 
 The Center
 
 
 
 Connecticut Children&rsquo;s Center for Care Coordination (The Center) is dedicated to the integration of care coordination through the delivery of innovative programs, providing technical assistance, disseminating best practices, and building inclusive partnerships to strengthen families and build stronger communities. The Center utilizes a universal, evidence based, research informed, and policy driven approach to enhanced care coordination that not only meets the interrelated medical, developmental, behavioral, and social needs of children, but enhances the care giving capacity of families. This team reports to The Center for their leadership.
 
 
 
 Position Details
 
 
 
 The Portal of Entry Utilization Management Nurse (POE) has strong clinical skills and a well-developed knowledge of utilization management, with a focus on medical necessity determinations. The candidate should possess a working knowledge of medical necessity tools such as InterQual&reg; and Milliman Care Guidelines&reg; and be proficient in medical record reviews. This individual supports the Care Management program by developing and/or maintaining effective and efficient processes for determining the defensible hospitalization status based on regulatory and reimbursement requirements of various commercial and government payers. The purpose of the POE is to support the physician and other qualified practitioners in determination of defensible patient class at the time of admission in the ED. The POE serves as a resource to all members of the health care team on defensible patient status and promotes effective utilization of hospital resources.
 
 
 This individual maintains current and accurate knowledge regarding commercial and government payers including regulatory requirements. The POE nurse will function in accordance with facility policies and processes. This individual will support process improvement activities and report key metrics to facility leadership as requested. audiences. The POE Nurse effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment. The POE Nurse participates and provides support to the hospital&rsquo;s Utilization Management Committee. They collaborate with multiple leaders at various levels throughout the organization. This is an on-site role interfacing with the admitting physician on cases to support industry-accepted level of care criteria.
 
 
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Performs chart review of assigned patients to identify quality, timeliness, and appropriateness of patient care. Conducts hospitalization reviews based on appropriate guidelines. Uses these criteria to screen for defensible level of care based on medical record documentation. Escalates cases as appropriate for secondary review. -15%
 </li>
 <li>
 Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals for secondary review. Identifies, develops, and implements strategies to reduce length of stay and resource consumption in conjunction with discharge planning staff. -15%
 </li>
 <li>
 Provides consultation and education to physicians and other qualified practitioners regarding medical record documentation necessary to support the ordered level of care. -10%
 </li>
 <li>
 Performs and documents initial / admission medical necessity review for all points of entry. -10%
 </li>
 <li>
 Communicates initial medical necessity review results with emergency department and admitting providers as necessary to support defensible admission status orders. -10%
 </li>
 <li>
 Proactively collaborates with emergency department providers and staff to identify patients likely to require hospitalization. -10%
 </li>
 <li>
 Works in conjunction with emergency department social workers and other staff to identify and secure available and necessary services to support clinically appropriate hospital admission avoidance. -3.0%
 </li>
 <li>
 Obtains information from patient, caregivers, providers of services, insurance company, benefits administrators and others as necessary. - .5%
 </li>
 <li>
 Conveys benefit data and options, programs and other forms of assistance that may be available to the patient, and negotiates for services as indicated. -.5%
 </li>
 <li>
 Communicates pertinent reimbursement information to healthcare team while observing patient right to confidentiality. -.5%
 </li>
 <li>
 Verifies in-network verses out-of-network benefits and communicates data to the patient and healthcare team as indicated. -.5%
 </li>
 <li>
 Pre-Admission Reviews -15%
 </li>
 <ul>
 <li>
 Performs prospective medical record review of patients scheduled for outpatient/inpatient procedures scheduled in the hospital setting.
 </li>
 <li>
 Works in collaboration with Finance to identify the appropriate setting for scheduled admissions, procedures, and medication administration by reviewing pertinent clinical information and collaborating to obtain prior authorization when necessary.
 </li>
 <li>
 Screens scheduled patients to ensure that they are scheduled in a defensible utilizing industry-accepted level of care criteria.
 </li>
 <li>
 Is able to review and interpret the patient&rsquo;s medical record to supply appropriate information to third-party payers as necessary.
 
 
 
 </li>
 </ul>
 </ul>
 Additional Responsibilities -5%
 
 
 <ul>
 <li>
 Collaborates with other members of The Center team to coordinate the right care, in the right setting, at the right time for CT Children&rsquo;s patients.
 </li>
 <li>
 Assist with discharge planning as necessary to coordinate the right care, in the right setting and the right time for CT Children&rsquo;s patients.
 </li>
 <li>
 Identify gaps in care/resources and address issues that negatively impact access to care, services, and resources
 </li>
 <li>
 Function as a change agent, advocate, and resource person for family and healthcare team to identify and resolve performance improvement issues within the system.
 </li>
 <li>
 Commitment to ONE TEAM Culture. -2.5%
 </li>
 <li>
 Performs other job-related duties as assigned. -2.5%
 
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 
 Education and/or Experience Required:
 
 
 
 <ul>
 <li>
 Education: Bachelor of Science in Nursing (BSN)
 </li>
 <li>
 Experience: 3 years of nursing experience in a healthcare setting
 
 
 
 </li>
 </ul>
 
 Education and/or Experience Preferred:
 
 
 
 <ul>
 <li>
 Experience:
 </li>
 <ul>
 <li>
 Pediatric nursing experience
 </li>
 <li>
 Previous experience in Utilization Review
 </li>
 <li>
 Previous experience in Case Management or Discharge planning
 
 
 
 </li>
 </ul>
 </ul>
 
 License and/or Certification Required:
 
 
 
 <ul>
 <li>
 State if Connecticut Nursing License.
 
 
 
 </li>
 </ul>
 
 License and/or Certification Preferred:
 
 
 
 <ul>
 <li>
 Case Management Certification.
 
 
 
 </li>
 </ul>
 
 Knowledge, Skills and Abilities:
 
 
 
 Knowledge:
 
 
 <ul>
 <li>
 Demonstrate working knowledge of how to interpret and apply medical care criteria.
 </li>
 <li>
 Knowledge of community resources, treatment options, home health availability, funding options and special programs.
 
 
 
 </li>
 </ul>
 Skills:
 
 
 <ul>
 <li>
 Coordinates management of care for a specified patient population; follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with hospital standards
 </li>
 <li>
 Provides ongoing support and expertise through comprehensive assessment, care planning, plan implementation and overall evaluation of individual patient needs.
 </li>
 <li>
 Skilled in the operation of the computer including proficiency in Microsoft Office Word, ability to use/update Excel spreadsheets and ability to navigate EPIC.
 
 
 
 </li>
 </ul>
 Abilities:
 
 
 <ul>
 <li>
 Self-directed/motivated, organized, diplomatic and team-oriented.
 </li>
 <li>
 Function in a high energy, fast moving environment.
 </li>
 <li>
 Maintain flexibility as determined by acuity of medical unit.
 </li>
 <li>
 Prioritize case load.
 </li>
 <li>
 Collaborate with various disciplines.
 </li>
 <li>
 Communicate effectively and efficiently.
 </li>
 <li>
 Prioritize and manage multiple tasks.
 </li>
 <li>
 Excellent written and verbal communication skills.
 
 
 
 </li>
 </ul>
 
 About Us
 
 
 
 Connecticut Children&rsquo;s is the only health system in Connecticut that is 100% dedicated to children. Established on a legacy that spans more than 100 years, Connecticut Children&rsquo;s offers personalized medical care in more than 30 pediatric specialties across Connecticut and in two other states. Our transformational growth establishes us as a destination for specialized medicine and enables us to reach more children in locations that are closer to home. Our breakthrough research, superior education and training, innovative community partnerships, and commitment to diversity, equity and inclusion provide a welcoming and inspiring environment for our patients, families and team members.
 
 
 At Connecticut Children&rsquo;s, treating children isn&rsquo;t just our job &ndash; it&rsquo;s our passion. As a leading children&rsquo;s health system experiencing steady growth, we&rsquo;re excited to expand our team with exceptional team members who share our vision of transforming children&rsquo;s health and well-being as one team.
</div>

Portal of Entry (ED) Utilization Management Nurse- 32hr- Onsite

WellSpan Health

<div>Full time

Monday-Friday 0800-1630

No Holidays and Occasional weekend

General Summary

Performs a variety of duties and applies utilization and case management techniques to determine the most efficient use of resources to facilitate a patient's progression of care and the provision of appropriate, cost effective and quality health care. Works in a team model with social work in assigned patient care areas to address patient discharge needs. Provides leadership in the integration of utilization and case management principles.
Duties and Responsibilities 
 
Essential Functions:
<ul>
<li>Reviews assigned patients for medical necessity, utilization management, and appropriateness of setting for continued hospitalization.</li>
<li>Initiates problem-solving techniques to prevent over and/or under utilization.</li>
<li>Facilitates and coordinates the progression of patient care to optimize throughput and the utilization of resources to support continuous quality and cost of care efforts.</li>
<li>Liaisons between utilization management team, third party payers, and the treatment team regarding the identified treatment plan in accordance with contractual guidelines and System policy.</li>
<li>Assists the patient care team with the identification and coordination of alternative treatment settings to provide appropriate care, maintain quality of care, and reduce cost.</li>
<li>Identifies conditions which require case management across the care continuum. Collaborates with members of the patient care team to identify interdisciplinary needs</li>
<li>Collaborates with care management across the system to effectively transition patient care and support value-based care initiatives.</li>
<li>Completes case management patient assessment, identifies needs, develops a discharge plan, and coordinates discharge needs (DME, Home Health, IV antibiotics, etc.) in collaboration with patients, families, and care team.</li>
<li>Assists with the collection and analysis of utilization patterns, length of stay, readmissions, avoidable days, and denied cases.</li>
<li>Brings known or suspected problems of under-, over-, or inappropriate utilization of resources to the attention of the appropriate manager(s).</li>
</ul>
Common Expectations:
<ul>
<li>Demonstrates a commitment to patient, visitor, and staff by complying with all applicable safety regulations, learning the impact of medical errors and methodology that will lead to reduction of errors; reporting actual and potential errors, as well as hazardous conditions; identifying opportunities to standardize processes and &ldquo;error proof&rdquo; systems that will lead to increased safety; and participating in safety education programs and root cause analyses as required.</li>
<li>Prepares and maintains appropriate documentation as required.</li>
<li>Maintains established policies and procedures, objectives, quality assessment and safety standards.</li>
<li>Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.</li>
<li>Prepares and presents utilization data analysis as required.</li>
<li>Participates in the development and delivery of educational information and process improvements related to job accountabilities and case management principles.</li>
<li>Attends meetings as required.</li>
</ul>
Benefits Offered:
<ul>
<li>Comprehensive health benefits</li>
<li>Flexible spending and health savings accounts</li>
<li>Retirement savings plan</li>
<li>Paid time off (PTO)</li>
<li>Short-term disability</li>
<li>Education assistance</li>
<li>Financial education and support, including DailyPay</li>
<li>Wellness and Wellbeing programs</li>
<li>Caregiver support via Wellthy</li>
<li>Childcare referral service via Wellthy</li>
</ul>
Qualifications 
 
Minimum Education:
<ul>
<li>Associates Degree Required</li>
<li>Bachelors Degree Preferred</li>
</ul>
Work Experience:
<ul>
<li>2 years Recent acute care experience Required</li>
<li>Field of Experience in Utilization Management, Case Management, or Clinical Nursing Specialty. Preferred</li>
</ul>
Licenses:
<ul>
<li>Licensed Registered Nurse Upon Hire Required or</li>
<li>Registered Nurse Multi State License Upon Hire Required and</li>
<li>Basic Life Support Upon Hire Required</li>
<li>Certified in Case Management Preferred</li>
</ul>
Knowledge, Skills, and Abilities:
<ul>
<li>Excellent interpersonal and communication skills.</li>
<li>Basic computer skills.</li>
<li>Desire and ability to work in a supportive and collaborative team environment.</li></ul></div>

Case Manager - Full time

HMSA

<div>
 
 Employment Type
 
 
 
 Full-time
 
 
 
 Exempt or Non-Exempt
 
 
 
 Exempt
 
 
 
 Job Summary
 
 
 
 
 Hybrid Work Environment - Must reside in Hawaii
 
 
 
 
 Pay Range:
 
 $59,000 to $116,000
 
 
 
 Note
 
 : Individuals typically begin between the minimum to middle of the pay range
 
 
 Under minimal supervision, conducts detailed analysis and review of precertification requests, post-service and suspended claims, by applying clinical expertise against HMSA medical and reimbursement policies, plan benefits and nationally accepted clinical guidelines to determine appropriateness of care for all HMSA lines of business.
 
 
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Associates degree in Nursing.
 </li>
 <li>
 Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN.
 </li>
 <li>
 Two years clinical, case management or utilization management related experience.
 </li>
 <li>
 Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures.
 </li>
 <li>
 Strong organizational skills
 </li>
 <li>
 Good communication skills both verbally and written
 </li>
 <li>
 Analytical skills
 </li>
 <li>
 Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
 </li>
 <li>
 Currently licensed in Hawaii as an RN or LPN
 </li>
 <ul>
 <li>
 (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)
 
 </li>
 </ul>
 </ul>
 
 Duties And Responsibilities
 
 
 
 <ul>
 <li>
 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
 </li>
 <ul>
 <li>
 Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
 </li>
 <li>
 Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
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 Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
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 Review various types of services, including but not limited to:
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 Transplants
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 Air Ambulance
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 Chemotherapy
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 Clinical trials
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 Genetic testing
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 Cancer treatments/radiation therapy
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 Experimental/Investigational Services/Devices
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 New Technology
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 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
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 Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
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 Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
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 Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
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 Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
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 Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
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 Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
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 Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
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 Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.
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 Performs all other miscellaneous responsibilities and duties as assigned or directed.
 
 
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Nurse Reviewer - Clinical Review Unit

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