RN Coordinator Utilization Management

The RN Coordinator Utilization Management reviews submitted authorization requests for medical necessity, appropriateness of cares and benefit eligibility. This individual also reviews applicable guidelines regarding payment and coverage, and makes determinations for authorization/payment.

Job Responsibilities:

• Demonstrates commitment and behavior aligned with the philosophy, mission, values and vision of Network Health
• Appropriately applies all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies
• Evaluates and processes prior authorization requests/referrals submitted from contracted and non-contracted providers.
• Follows Network Health process, policies, and procedures in authorization review of all membership on a pre-service, concurrent and post-service basis. This process includes verifying eligibility and benefits, as well as documenting all utilization management communication.
• Provides education regarding utilization management activities and processes to members, caregivers, providers, and their administrative staff.
• Participates in Utilization Management auditing (i.e. Utilization Management Inter-reviewer reliability and denial files).
• Refers all members with complex health problems and needs to Network Health Case Management to reduce medical costs while providing a higher quality of life and an ability to take charge of their diseases. This requires an extensive holistic approach to care management assessment.
• Collaborates with other NH departments to develop interdepartmental operational processes.
• Supports Utilization Management department programs and goals through active participation.
• Identifies and screens candidates for Case Management intervention and determines appropriate level of care from Utilization Management criteria.
• Completes assessments and plans of care including need for medication regime, treatment plans, practitioner follow-up appointments, knowledge of red flags, disease management, Advance Directives, life planning, and self-management of illness to the best of member ability.
• Evaluates cases for cost savings/quality improvement potential.
• Performs other duties and responsibilities as assigned.

Job Requirements:

• Bachelor of Science in Nursing, preferred.
• Associate Degree in Nursing, required.
• Minimum of four (4) years clinical health care experience as a Registered Nurse (RN).
• Experience in insurance, managed care and utilization management preferred.
• Current registered nurse licensure in Wisconsin required.

Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required).

We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.