Utilization Management NurseMedical Associates, Dubuque, IA
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Our mission is to provide superior healthcare and an excellent patient experience.
Medical Associates Clinic is a well-established multispecialty group practice with over 170 providers and a staff of over 1,000 health care professionals and support personnel. The group was founded in 1924 and is Iowa’s oldest multispecialty group practice. Today, Medical Associates Clinic is the area’s leading health care provider and only multispecialty group practice. Medical Associates Clinic has been recognized since 1998 as a “better performing practice” by the Medical Group Management Association.
In 1982, Medical Associates developed the Tri-State’s first health maintenance organization, Medical Associates Health Plans, which offers comprehensive health benefits to over 400 employers and 45,000 members. Medical Associates Health Plans has maintained an “Excellent” rating, the highest level of accreditation possible by the National Committee for Quality Assurance, for 13 consecutive years.
Medical Associates Clinic offers several locations from which to seek medical care, including facilities at 1500 Associates Drive, 1000 Langworthy, and 1940 Elm Street in Dubuque, Iowa; as well as facilities in Bellevue, Cascade, Dyersville, Elkader, and Monona, Iowa; Cuba City, and Platteville, Wisconsin; and Elizabeth and Galena, Illinois.
Utilization Management RN position may be your next step! Assist physicians, providers and Health Plan members through the referral and pre-certification process for services including: in-patient and out-patient services, durable medical supplies and referrals to specialty care. Clinic, hospital or health plan experience preferred. Schedule is Mon - Fri, 8am to 5pm.
Coordinates and manages the continuance of patient care through a systemic collaborative approach which includes: assessment, planning, implementation, evaluation and interaction. Utilize established screening criteria to ensure patients get the correct treatment from the resources that are available at the most cost effective level to meet the their needs. Facilitate options and services for meeting individuals’ health needs with the goal of decreasing fragmentation, duplication of care and enhancing quality, cost-effective clinical outcomes. Monitor general utilization patterns of assigned groups to detect trending patterns.
Essential Functions & Responsibilities:
Conduct reviews inclusive of physician referrals, medication reviews, admissions, utilization review updates, investigating alternatives to hospitalization such as home health care and durable medical equipment, utilizing the assessment process by obtaining pertinent patient history and accurate vital data, anticipating patient and family needs, working with the Health Choice Claims and Membership Services to determine benefit eligibility, facilitating crisis intervention, sharing information with co-workers and documenting accurately. Utilize established screening criteria to determine medical necessity of requested authorizations. Refer patients to case management nurse or health coach as appropriate.
Facilitate out-of-plan referrals, out-of-area urgent and emergent care for enrollees and provider offices and provide necessary information to Medical Director on specified referrals. Communicate decision to enrollees, providers, and facilities per established policies.
Work collaboratively with internal and external staff, in determining extent of benefits and coverage for services being coordinated. Document authorizations, denials, cost savings and other outcome measurements.
Act as a resource for the enrollee, provider offices, and other MAHP departments. Perform retrospective review to determine coverage of hospitalizations, and outpatient services. Communicate with enrollees regarding the use of managed care systems and participate in answering enrollees and providers inquiries.
Assist in preparations for external review/regulatory agencies.
Knowledge, Skills and Abilities:
Experience - Three years to five years of similar or related experience.
Education - Valid RN nursing license is required.
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Paid Sick Leave
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