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RN Utilization Management - Lead
at Centura Health
- SCP FULLWELL CARE MANAGEMENT
- Dry Creek
- Work Type
- FLSA Status
Welcome to Centura Health
Welcome to the largest health ecosystem in Colorado and western Kansas. Welcome to living your mission among thousands of people on fire to live theirs too. Welcome to options, possibilities and values that guide exceptional care. Welcome to extremely important industry challenges and opportunities to solve complex problems. Welcome to highly intelligent teams, overflowing community and the wholeness of mind, body and spirit that is Centura Health.
Flourishing Begins Here
You have a purpose, unique talents and NOW is the time to embrace it, live it and put it to work. At Centura Health, we value incredible people with incredible skills – but your commitment to a greater cause is something we value even more.
Applying clinical judgment and critical thinking, the Utilization Management RN will perform concurrent and retrospective review of members' admission (through discharge) for inpatient hospital, skilled nursing facility, acute rehabilitation, long term acute facility admissions and all preauthorization requests for services applying appropriate medical necessity criteria/guidelines. Works closely with the Medical Director of UM when determinations for medical necessity or continuedn length of stay cannot be completed at the nurse level. Utilizing a high-risk stratification tool, identifies members qualified for care coordination programs; collaborating closely with the Care Coordinators. Reviews will be performed telephonicallyor through use of facility electronic health records (E.H.R.). Under the direction of the department Medical Director, the UM RN will perform clinical review and auditing of the members letters for accuracy and clarity for all adverse determinations generated by the UM department.
This role will serve as a technical subject matter expert to the UM team and will follow/maintain health plan procedures for Appeals and Grievances. Additionally, role is responsible for monitoring and reporting compliance issues for delegated functions of UM (internal and external), interfacing with health plans, including delegated reporting requirements.
What You Bring/Job Requirements
In addition to bringing your whole self to the workplace each day, qualified candidates will need the following:
- 5 years of previous nursing experience.
- Extensive UM experience in health plan, hospital or TPA, including operations experience.
- 2 years referrals management or related experience preferred.
- Knowledge of medical terminology and CPT/ICD-10 coding preferred.
- Knowledge of NCQA and Medicare/Medicaid guidelines, community resources, and agencies preferred.
- Bachelors degree in nursing required or Bachelor's degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college.
- Colorado RN license required
Sedentary work -(prolonged periods of sitting and exert up to10lbs force occasionally)
Your Connected Community
When people and places align, incredible things happen. Just like the 21,000+ amazing associates who work here, every community within Centura Health’s connected ecosystem has its own unique history, story and personality.
FullWell provides population health management services to Centura Health’s clinically-integrated network of independent affiliates, along with our employed providers and associates. The FullWell team includes care managers, quality and coding specialists, utilization management staff, and reporting/analytics experts focused on tools and services to improve efficiency and effectiveness across various member populations, including Medicare Advantage (MA) and Accountable Care (ACO) contracts).