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RN - Utilization Management (Medicaid)

Company: Carewise Health
Location: Louisville
Posted on: July 15, 2019

Job Description:

The Utilization Management Nurse is responsible for the delivery of the Utilization Management process to include: making clinical recommendations regarding medical necessity for admission, continued stay and the development/implementation of a comprehensive case management treatment plan.ESSENTIAL FUNCTIONS:Responsible for the telephonic and fax delivery, of the Utilization Management process to include: assessing, planning, implementing and, coordinating clinical recommendations regarding medical necessity for admission, continued stay and the development / implementation of a basic case management treatment plan.Collects in-depth information regarding a patients clinical history, prognosis, treatment plan, response to treatment, access to care, access to personal and community resources, utilization of care, personal coping mechanisms, learning needs and financial constraints.Determine specific short and long-term goals, objectives, and interventions with accompanying timeframes.Screens for cases which do not meet the client specific guidelines, i.e. physician developed criteria, Medicare and/or Medicaid guidelines and refers them to the Medical Panel accordingly. -Establishes a quality check date using client specific guidelines.Utilizes nursing experience and judgment in addition to the client specific guidelines when determining medical necessity and quality check dates.Performs multiple tasks within the review process including knowledge of different systems, reviewing for multiple clients and the ability to interpret and apply multiple benefit configurations to the review process.Monitors daily work flow queues and performs necessary calls to ensure completion of reviews according to department procedure. -Responsible for maintaining expected quality standards,Offers suggestions for improvement in the review process.Maintains a courteous and professional manner in all interactions, whether with clients or co-workers.Perform discharge planning for the member if necessary and allowed by client contract.Other duties as assigned.EOE Disability/VeteransRequired SkillsRequirements:Associate's degree in nursing.. Bachelor's degree preferred.Unrestricted & active Kentucky Registered Nurse. License.A minimum of three years clinical nursing experience preferred.A minimum of three years utilization management experience preferred. Intermediate level skills in Microsoft applications (Excel, Word, Outlook, and Windows environment).Excellent verbal and written communication skills.Organization and time management skills are essential.Must be able to successfully complete any required pre-employment testing.Carewise Health provides a generous benefits package including:Medical InsuranceDental InsuranceLife InsuranceVision InsurancePaid VacationPaid HolidaysPaid Sick DaysShort Term DisabilityLong Term Disability401K Plan With Company MatchTuition ReimbursementEmployee Assistance ProgramAll benefits are effective on the 29th day of employment with the exception of tuition reimbursement and STD, which is effective after 90 days of employment.Job Location Louisville, Kentucky, United States Position Type Full-Time/RegularThe Courier Journal. Keywords: Utilization Review Nurse, Location: Louisville, KY - 40204

Keywords: Carewise Health, Louisville , RN - Utilization Management (Medicaid), Executive , Louisville, Kentucky

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