Utilization Management Nurse Job Description
Utilization management nurse
provides advanced Skills in MS Excel, SharePoint Online and other M365 applications (Word, PowerPoint and Outlook).
Utilization Management Nurse Duties & Responsibilities
To write an effective utilization management nurse job description, begin by listing detailed duties, responsibilities and expectations. We have included utilization management nurse job description templates that you can modify and use.
Sample responsibilities for this position include:
Ambulatory surgery procedures
Referrals to MD's out of network
Reviewing durable medical equipment requests
Collaborate with other members of the health care team to identify appropriate utilization of resources and to ensure reimbursement
Oversee utilization management for patients within the assigned caseload
Utilize criteria to confirm medical necessity for admission and continued stay
Ensure high quality, cost efficient medical outcomes for those patients identified as having the need for inpatient hospitalization
Screen patients for Intensive Case Management programs including case management and disease management
Pre-certify all focused list of outpatient services
Document clinical information into the Care Management system
Utilization Management Nurse Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Utilization Management Nurse
List any licenses or certifications required by the position: CCM, ACM, MCG, CPR, CM, PRI, BLS, UM
Education for Utilization Management Nurse
Typically a job would require a certain level of education.
Employers hiring for the utilization management nurse job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, Education, School of Nursing, Science, Graduate, Management, Department of Education, Nursing Education, Health Care, Medical
Skills for Utilization Management Nurse
Desired skills for utilization management nurse include:
Microsoft Word
Outlook and Excel
Milliman Criteria
Job area typically obtained through advanced education combined with experience
CPT-4
HCPCs
Benefit plans used to complete review decisions
Outlook and Excel with the ability to type and enter data accurately
Hospital billing patterns
ICD-9
Desired experience for utilization management nurse includes:
Review and refer all cases that are not meeting Criteria or Medical Policy to the Medical Director for determination of initial or continued services
Initiate the pre-certification process with the appropriate facility and/or provider using Criteria and Medical Policies
Confirm outpatient services
Enter subscriber data as indicated
Maintain Utilization Review forms, logs and statistics
Attend Ancillary Nurse clinical review meetings on a weekly basis
Utilization Management Nurse Examples
1
Utilization Management Nurse Job Description
Job Description Example
Our innovative and growing company is hiring for an utilization management nurse. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for utilization management nurse
- Performs an evaluation of the request appropriateness for CareCentrix-sourced services based on the Medical Guidelines of the insurer
- Participates in and contributes to ongoing utilization management activities and quality assessment/improvement activities, ensures the collection of data for improvement analysis and prepares reports as requested
- Learn and use the company's tools and processes to perform and properly track all utilization reviews, as well to refer members for further care engagement when needed
- Perform discharge planning, ancillary and outpatient review
- Perform health assessments to identify problem areas for patients
- Establish patient care plans
- Interact with and obtain relevant clinical information from patients
- Educate patients on outlined health issues
- Maintain comprehensive case notes
- Document all interventions
Qualifications for utilization management nurse
- This role will require 75% travel throughout the Greenville, SC area
- Current and unrestricted RN License in the State in which you reside
- Over three years and up to and including five years of experience of UM in a Medical Group or Health Plan setting
- Three to five years of acute nursing experience in critical care
- Knowledge of NCQA and Medicare/ Medicaid guidelines, community resources and agencies
- Implements and monitors current utilization management programs within the policies and procedures set by the Utilization Management department
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Utilization Management Nurse Job Description
Job Description Example
Our company is growing rapidly and is looking for an utilization management nurse. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for utilization management nurse
- Conducting initial medical necessity review of exception pre-authorization requests for services requested outside of the client health plan network
- Notifying the Ordering Physician or rendering service provider office of the pre-authorization determination decision
- Following-up, as necessary, to obtain additional clinical information as applicable
- Ensuring proper documentation, provider communication, and telephone service per department standards and performance metrics
- Evaluates clinical documentation on multiple patient accounts and escalates issues through the established chain
- Of command
- Demonstrates a working knowledge of managed care agreements based on available resources which may include
- And not be limited to payer UM Manual, policy and procedure, facility contract information
- Monitors self-compliance and implements process changes to ensure compliance to such regulations and quality
- Adhere to all policies and procedures, including, attendance, phone and internet usage, break utilization
Qualifications for utilization management nurse
- Experience using nationally accepted criteria (Interqual, Milliman)
- Conducts on-site or telephonic prospective, concurrent and retrospective review of active patient care, including out-of-area, transplant, and Behavioral Health
- Reviews patients’ clinical records within 48 hours of a post-acute admission
- Consults with physician and other team members to ensure that referral is successfully implemented
- Communicates authorization or denial of services to appropriate parties
- Participates actively in assigned committee meetings
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Utilization Management Nurse Job Description
Job Description Example
Our growing company is looking for an utilization management nurse. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for utilization management nurse
- Obtain necessary documentation for a determination to be rendered
- Utilize Review Criteria to pre-screen prior authorization requests for medical necessity and appropriateness
- Coordinates with the Medical Director / Physicians for those requests outside of standard Review Criteria
- Respond to emergent and expedited / urgent authorization request with priority and timely/referral turnaround time to facilitate compliance with health plan / AHCA Contractual standards
- Refer cases for which criteria are not met to the Medical Director when unable to resolve within contracted timeframe
- Serve as a liaison between the Medical Director, Physicians and office staff in resolving prior authorization questions, issues and problems
- Assure medical management adherence to company and department policies and procedures regarding confidentiality
- Analyze and review findings and identifies trends requiring referral to the Medical Management Department leadership
- Perform evaluation and concurrent monitoring of appropriate utilization of durable medical equipment, hospitalizations, home healthcare, infusion services and long-term rehabilitation
- Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information
Qualifications for utilization management nurse
- Demonstrates a thorough understanding of the cost consequences resulting from Utilization Management decisions through utilization of appropriate reports
- Ensures appropriate utilization of medical facilities and services within the parameters of the patients’ benefits
- Initiates and oversees data entry into RMS of all patients within the parameters of UM policies and procedures
- Manage Network participation, care with specialty networks, care with DME providers and transfers to alternative levels of caring using knowledge of benefit plan design
- Bachelor’s degree in Health Care Administration, Health Care Informatics, or related field
- 2 years referrals management or related experience, preferred
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Utilization Management Nurse Job Description
Job Description Example
Our innovative and growing company is hiring for an utilization management nurse. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for utilization management nurse
- Provide quality utilization management will reduce health care costs and expenses
- Review of durable medical equipment requests
- Ensures that services are delivered and documented in a manner that balances quality of care with efficiency, cost containment and compliance
- Reviews for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria
- Contribute.Maximizing accuracy of level of care with the insurance companies in order to reduce denials and increase compliance, while leveraging expertise from the utilization management team
- Completing the Utilization Management (UM) data collection form
- Documenting into Computerized Patient Record System (CPRS)
- Notifying facility of authorization of Emergency Department visits
- Completing admission pre-certification and concurrent reviews on same day or next business day
- Establishing work priorities to accomplish assignments timely, achieve program system goals and meet established criteria
Qualifications for utilization management nurse
- Knowledge of medical terminology and CPT/ICD-10 coding, preferred
- Knowledge of NCQA and Medicare/ Medicaid guidelines, community resources and agencies, preferred
- Experience in software training of UM staff
- Develops and updates training materials and desk level procedures for UM
- Audits teams for appropriate and consistent documentation in the RMS.*
- Participates in special projects related to the RMS
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Utilization Management Nurse Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of utilization management nurse. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for utilization management nurse
- Notifying appropriate services when problem/issues occur
- Facilitating discharges planning in consultation with the physician, patient, family and appropriate health care team members
- Working with the contracted facility case managers or social worker and VHA social work to facilitate discharge planning
- Consulting with PUMA when stay does not meet InterQual criteria, nor quality of care issues
- Actively participating with the adherence/establishment/modification of policies, procedures and standards to promote and improve evidence-based patient driven care
- Participates in departmental cost containment
- Proactively analyze information submitted by providers to make timely medical necessity review determinations based upon evidence based clinical criteria and standards within governmental and contractual guidelines
- Identify and present cases of possible quality of care deviations, questionable admissions and prolonged lengths of stay to the Medical Director for further determination
- Collects accurate data for system input by using correct coding of diagnoses and/or procedures
- Processes authorization requests via phone queue according to internal departmental processes
Qualifications for utilization management nurse
- Provides end user support during all aspects of the RMS implementation.*
- Has strong technical skills to assist with the RMS build, these skills will translate to work flows for the UM department.*
- Is the Super User for the RMS
- Participates in training internally and with providers.*
- Assists with configuration of the RMS implementation.*
- First response for member and provider complaints or concerns.*