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UTILIZATION MANAGEMENT RN

Liberty Health
place Wilmington, 28403
Experience:
Avoidant Personality Disorder
ECT
School
In-patient Non-Psychiatric
In-patient Psychiatric
Partial Hospitalization (PHP)

About Job


UTILIZATION MANAGEMENT RN

Wilmington-NC-28401-United States

There’s no place like Liberty Health

Come explore career opportunities with Liberty Health, a dynamic leader in the healthcare industry. Join us!

We are currently seeking an experienced:

UTILIZATION MANAGEMENT RN

Full Time, Days

JOB SUMMARY:

  • Day-to-day management of Utilization Management queues, dashboards, members, ensuring all Utilization Management activities, which include authorization timeliness, discharge planning, adherence to policies and procedures to ensure high quality and cost-effective utilization management services.
  • Ability to work decision letters timely and accurately
  • Quality monitoring focusing on medical necessity guidelines and discharge planning opportunities to lower levels of care
  • Assist the Director of Utilization Management with the Utilization Management Reports to be reviewed by Executive Leadership.
  • Ability to contribute to the UM team to ensure compliant execution of UM program
  • Review admissions and service requests for the following:
    • Authorization requests to ensure appropriate care for members and within clinical guidelines
    • Monitor members both inpatient/outpatient – provide updates to Director of Utilization Management and the clinical care teams
    • Recommend more appropriate care if required
  • Assess and coordinate discharge planning with Care Team.
  • Assist co-workers with issues related to coding, medical records/documentation, pre-certification reimbursement and claim denials/appeals.
  • Use critical thinking and problem-solving to navigate through the complexities of a member’s health conditions while maintaining coverage within the program guidelines.
  • Ability to focus on interventions for improvement
  • Provides appropriate responses to providers regarding UM questions or direct these questions to the Director of Utilization Management
  • Monitors utilization management queues and dashboards, assuring compliance with reporting and turnaround times.
  • Participates in the interdisciplinary approach to support continuity of care
  • Participates in the Case Management processes and assists with the development of case management programs
  • Ability to participate and contribute with the written policies and procedures and workflows
  • Ability to participate in the On-Call rotation to ensure timeliness is maintained
  • Ability to work occasional after hours to ensure timeliness is maintained.
  • Contribute to and attend UM meetings and UM huddles.
  • Other duties as assigned
  • Less than 10% travel to the corporate office for Department meetings

JOB REQUIREMENTS:

  • Licensed Registered Nurse credentialed from an accredited school/college with 3–5 years of clinical experience
  • Maintain Active Registered Nurse License, (Compact, RN preferred)
  • 1–5 years managed care Utilization Management experience (preferably with a Health Plan)
  • Demonstrated experience in health plan utilization management, initial reviews, facility concurrent review discharge planning, and case management required.
  • Medicare Advantage experience required
  • Experience with InterQual or MCG authorization criteria preferred.
  • Excellent computer skills and the ability to learn new systems are required.
  • Strong attention to detail, organizational skills, and interpersonal skills are required.
  • Demonstrated ability to problem-solve and manage professional relationships.
  • Healthcare industry knowledge
  • Excellent listening, verbal, written and interpersonal communication skills.
  • High level of professionalism and confidentiality, with a strong customer focus.
  • Can adapt well to operational needs with excellent follow-up skills.
  • Must be self-motivated, with a work ethic of dedication and the discipline to work independently.
  • Must have a valid driver’s license.
  • Proven ability to communicate concisely and confidently with all staff levels. Clearly communicates instructions to remote users.

Visit www.libertycareers.com for more information.
Background checks/drug-free workplace.
EOE.






PI1bf8c000849b-37645-38039594

Professional Field

professional badgeOther Behavioral, Mental, or Healthcare Field

Patient Focus

Diagnoses

Avoidant Personality Disorder

Therapeutic Approach

Methodologies

ECT

Practice Specifics

Populations

School

Settings

In-patient Non-Psychiatric
In-patient Psychiatric
Partial Hospitalization (PHP)
Private Practice
Telehealth/Telemedicine
Home Health/In-home