Utilization Management RN

JOB TITLE: Utilization Management - RN (Non-Exempt) POSITION SUMMARY: Role expectations for Utilization Management Nurse includes assessing, organizing, implementing and evaluating the care and utilization across the continuum, to enhance quality patient care while simultaneously promoting cost effective resource utilization. This role performs utilization management, discharge planning, and screens for case management referrals. The Nurse assesses the needs of patients/clients and their significant others, while being aware of outcomes, costs, and processes. The nurse combines the roles of clinician and educator to accomplish desired clinical outcomes. RESPONSIBILITIES: · Knowledge of prospective payment systems, managed care vendor’s policies, infection control surveillance, patient care, disease processes, discharge planning and continuum of services offered with QCP and externally. · Knowledge of URAC Standards, other regulatory bodies and of QCP activities and services related to the comprehensive performance of duties. · Ability to compile a clinical review and knowledge and ability to utilize electronic documentation systems. · Excellent verbal and organizational skills to facilitate the case management process and ensure patients and customers are served promptly and with respect. · Clear documentation of medical necessity for all services. · Complete follow through for disposition of cases for Medical Director review, potential quality chart reviews, stop-loss notifications, and case management referrals. · Other duties as assigned. REQUIRED QUALIFICATIONS: · Current and active unrestricted licensure or certification to practice a health or human services discipline in a state or Territory of the United States. · Two years full time equivalent providing direct clinical care to the consumer. · Bachelors of Science in Nursing or Certification in specialty are Preferred. · Must have a valid driver’s license and reliable transportation. DEMONSTRATE QCP VALUES: The values of Quality Care Partners are demonstrated on a daily basis and reflected through job duties and responsibilities as evidenced by: ● Caring: Seek to listen, understand and respond to our customers’ needs with care; Communicate with co- workers and customers with positivity and empathy; Be good stewards of QCP resources. ● Excellence: Strive to exceed, not just meet expectations; Always deliver services with accuracy and efficiency; Recognize and utilize your strengths and the strengths of others. ● Improvement: Bring new ideas to create positive change and solutions; Be open to the ideas and suggestions of others; Be an advocate to continuously improve QCP. ● Accountability: Take ownership for your daily decisions; Stay focused on your job and eliminate distractions while at work; Demonstrate QCP values in everything you do. TRAITS AND APTITUDES: · High level of awareness of pertinent details; excellent organizational skills. · Excellent verbal and written communication skills. · Must handle pressure effectively. · Professional appearance and demeanor. · Able to maintain confidentiality. · Excellent computer literacy and skills with the ability to master programs needed for position. PHYSICAL DEMANDS AND WORK CONDITIONS: The physical demands 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. · Must have excellent written and verbal communication skills as well as the ability to observe, assess, guide and evaluate others. · Must be able to hear, speak, and see and to coordinate motor skills. · Must be able to climb, lift 25 pounds, stoop and bend and reach above head. · Ability to collect data, interpret findings, set priorities and carry out established plan. · Ability to read, write and utilize manual and computerized systems of documentation. · Must read a significant amount of information in a relatively short period of time. EEO STATEMENT: Quality Care Partners is an equal opportunity employer that is committed to inclusion and diversity. We take affirmative action to ensure equal opportunity for all applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, Veteran status, or other legally protected characteristics. REPORTING RELATIONSHIPS: Position Reports to: Health Services Manager Job Type: Full-time Pay: $29.82 - $34.98 per hour Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Experience:

• Payor Utilization Management : 1 year (Preferred)
• providing direct clinical care to the consumer full time: 2 years (Required)

License/Certification:

• current and active unrestricted RN licensure (Required)

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