Imagine360 specializes in transforming the healthcare experience by providing innovative solutions for self-funded health plans. With a mission to deliver bette
Utilization Management RN
Location
United States
Posted
10 days ago
Salary
0
Seniority
Mid Level
Job Description
Utilization Management RN
Imagine360
Role Description Imagine360 is seeking a Utilization Management, RN to join the team! The RN Utilization Management Nurse is responsible for providing utilization review/notifications and education for individuals under the group health plans administered by Imagine360 by utilizing nursing education, clinical, and professional experience. The Registered Nurse will practice within the scope of practice while performing assessments, coordination, planning, monitoring, and evaluation. Position Location: 100% remote - Perform all tasks in accordance with Department of Labor, HIPAA, ERISA and Care 360 department Policy and Procedures. - Complete HIPAA and URAC training annually. - Identify, collect, process and manage data to complete reviews for Medical Necessity per Imagine360 approved clinical guidelines. - Accurate utilization and documentation in appropriate software including time slips in CaseTrakker to complete and document the review process per Care 360 Policy and Procedure. - Provide oversight to non-clinical staff members regarding interpretation of clinical data. - Consult with Care 360 Physician Advisor or peer reviewer per policy and procedures. - Assess and review current treatment history to identify appropriate referrals to Case Management Program or other Care 360 Services. - Communicate professionally and effectively as needed with members, physicians, other healthcare professionals, peers, Supervisor of UM to complete the utilization process per Care 360 Policy and Procedures. - Utilize clinical knowledge, expertise and Imagine360 approved educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures and/or treatment. - Attend scheduled and periodic meetings, training and other job specific events as required either by teleconference or onsite. - Participate in the Quality Management program of the organization by completing the Quality Assurance review process and other procedures per policy and procedure. - Work regular scheduled hours and be available for additional coverage outside of normal working hours as needed. - Evaluate clinical data. - Assess and evaluate the acquired clinical data to assess for appropriateness of treatment plan based upon Imagine360 clinical guidelines. - Coordinate treatment plans, interventions and outcomes measurement. - Provide rationale for the effects of medication and treatments. - Provide patient education and educational resources. - Accurately report: Administration of medication and treatments, Client response, Contact with other health care team members. - Respect the client's right to privacy by protecting confidential information. - Promote and participate in education and counseling to a participant based on health needs. - Clarify any treatment that is believed to be inaccurate, non-efficacious, or contraindicated by consulting with appropriate practitioner. - Other duties as assigned. Qualifications - Nursing Degree from an accredited college or university and an active, current, and unrestricted Registered Nurse License in eNLC compact state. - Bachelor's degree preferred. - 1+ year in Utilization Management and/or Case Management experience. - Experience in utilization review services preferred. - Experience and knowledge of CPT and ICD coding preferred. Requirements - Ability to read and interpret documents such as HIPAA compliance, safety rules, operating and maintenance instructions, and policy and procedure manuals. - Ability to write routine reports and correspondence. - Ability to speak effectively to members and employees. - Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages. - Ability to apply concepts of basic mathematics and fundamental accounting principles. - Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. - Ability to deal with problems and exercise sound judgment involving several concrete variables in standardized situations. - Basic knowledge and skills using Microsoft Office Word, Internet software, and Database software. License and Certifications - Current, active, and unrestricted compact Registered Nurse license. Must maintain CEUs as required by the State Board of Nursing. - Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization. - Current Certified Case Manager (CCM) Certificate preferred; if Certification is not current, employee must pursue and achieve CCM Certification within three years of employment. Benefits - Multiple Health plan options. - Company paid employee premiums for disability and life insurance. - Parental Leave Policy. - 20 days PTO to start / 10 Paid Holidays. - Tuition reimbursement. - 401k Company contribution. - Company paid Short & Long term Disability plus Life Insurance. - Professional development initiatives / continuous learning opportunities. - Opportunities to participate in and support the company's diversity and inclusion initiatives.
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