Utilization Manager, Registered Nurse

Assesses member needs and identifies solutions that promote high quality and cost-effective health care services. Manages providers, members, team, or care manager generated requests for medical services and renders clinical determinations in accordance with healthcare policies as well as applicable state and federal regulations.  Delivers timely notification detailing clinical decisions. Coordinates with management, subject matter experts, physicians, member representatives, and discharge planners in utilization tracking, care coordination, and monitoring to ensure care is appropriate, timely and cost effective.  Works under general supervision.

 Duties and Responsibilities (including but not limited to)

• Conducts comprehensive review of all components related to requests for services which includes a clinical record review and interviews with members, clinical staff, medical providers, paraprofessional staff, caregivers and other relevant sources as necessary.
• Examines standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, level of care and lengths of stay.  Performs prior authorization and concurrent reviews to ensure extended treatment is medically necessary and being conducted in the right setting. Reviews requests for outpatient and inpatient admission; approves services or consults with medical directors when case does not meet medical necessity criteria.
• Ensures compliance with state and federal regulatory standards and VNS Health policies and procedures.
• Participates in case conferences with management.
• Identifies opportunities for alternative care options and contributes to the development of patient focused plan of care to facilitate a safe discharge and transition back into the community after hospitalization.
• Reviews covered and coordinated services in accordance with established plan benefits, application of evidenced based medical criteria, and regulatory requirements to ensure appropriate authorization of services and execution of the plan’s fiduciary responsibilities.
• Identifies and provides recommendations for improvement regarding department processes and procedures.
• Maintains current knowledge of organizational or state-wide trends that affect member eligibility and the need for issuance of Determination Notices
• Improves clinical and cost-effective outcomes such as reduction of hospital admissions and emergency department visits through on-going member education, care management and collaboration with IDT members.
• Provides input and recommendations for design and development of, processes and procedures for effective member case management, efficient department operations, and excellent customer service.
• Maintains accurate record of all care management. Maintains written progress notes and verbal communications according to program guidelines.
• Participates in approval for out-of-network services when member receives services outside of VNS Health network services.
• Provides case direction and assistance ensuring quality and appropriate service delivery.
• Keeps current with all health plan changes and updates through on-going training, coaching and educational materials.
• Issues Determinations, Notices of Action, and other forms of communication to members and providers which communicate VNS Health’s determinations.  Ensures all records/logs related to decision requests, Notices of Action, and other communications required by state or federal regulations are saved in the Utilization Management System.
• Reviews, evaluates and determines the appropriateness of requests, utilize the most appropriate clinical care guidelines based on clinical practice guidelines. Adheres to all federal and regulatory requirements.
• Evaluates and analyzes care and utilization trends/issues and identifies opportunities for better coordination of members’ care.

Qualifications or Education, Training and Experience

• Compact Licensed RN, California and New York State preferred
• Bachelor’s degree in nursing preferred; Associate degree in nursing is minimum requirement.
• Knowledge of Medicare and Medicaid regulations
• Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills.
• Working knowledge of Microsoft Excel, Power-Point, and Word and strong typing skills
• Knowledge of Medicaid and/or Medicare regulations
• Knowledge of Milliman criteria (MCG)
• For UM Only: Experience must be with a Managed Care Organization or Health Plan.
• Experience working with community-based organizations in underserved communities

Working knowledge of the following required:

• Principles of utilization management; care management principles; basic knowledge of health plan contracts and benefit eligibility requirements; Hospital structures, Managed Care and payment systems
• Timely and accurate documentation of day-to-day activities in designated technology platform
• Adaptable to new technologies and software
• Proficiency in EMR system(s), Outlook and data entry experience preferred
• Basic PC skills (MS Word/Outlook/PPT/Excel)

Examples of Competencies:

• Ability to use independent judgment and to manage and impart confidential information.
• Ability to analyze and solve problems; requires details, data and facts that must be analyzed and challenged prior to making decisions.
• Strong communication and interpersonal skills.
• Ability to clearly communicate medical information to professional practitioners and/or the public.

• Excellent organization, prioritization, follow up, analytical and time management skills with ability to handle multiple priorities and deadlines.
• Good interpersonal skills, sense of urgency, being proactive and ownership for one’s work.
• Dependable, with strong work ethic and extremely high degree personal integrity.
• Ability to deal with multiple interruptions on a continual basis that must be met with a friendly exchange with others.
• Ability to develop and implement new approaches to improve processes, procedures, or the general work environment.
• Ability to review critical issues, effectively solve problems and create action plans.

Benefits: As a firm passionate about health care, we’re deeply committed to the health and wellness of our own team members. We offer comprehensive, affordable insurance plans for our team and their families, and a host of other unique benefits, such as a yearly stipend for wellness-related activities and a paid parental leave program. You can learn more about our benefits offerings here: https://copehealthsolutions.com/careers/why-cope-health-solutions/.  About COPE Health Solutions
COPE Health Solutions is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive NCQA certified population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers. For more information, visit CopeHealthSolutions.com. To Apply: To apply for this position or for more information about COPE Health Solutions, visit us at https://copehealthsolutions.com/careers/open-positions/.