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Utilization Management Nurse

Medical Associates, Dubuque, IA

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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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Job Details

Req Num --
ID 496915
Dubuque, IA
Positions 1
Full Time
Pay --
Health Care
Health Insurance
Dental Insurance
Life Insurance
Retirement Plan
Paid Vacation
Paid Sick Leave
Paid Holidays

Preferred Candidates

Years of Experience --
Education --

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