Utilization Management Nurse (RN) - Case Management - Day

Schedule

Full Time: 40 Hours/Week

Hours: Monday - Friday 8am - 4:30pm

Weekend Rotation Required

This is a remote position that requires candidates to be located within 50 miles of WellSpan's geographic footprint in South Central Pennsylvania or in Northern Maryland. Occasional travel is required within WellSpan's geographic footprint.

General Summary

Performs a variety of reviews and applies utilization and case management techniques to determine the most efficient use of resources to support the provision of appropriate, cost effective and quality health care. Provides leadership in the integration of utilization management principles throughout the System. Responsible for screening patients for care management programs, including bundles and complex care management.

Duties and Responsibilities

Essential Functions:

• Performs initial reviews for medical necessity and appropriateness of setting for the assigned case load.
• Conducts concurrent reviews to ensure medical necessity for continued hospitalization and initiates problem-solving techniques as needed to prevent over and/or under utilization. Refer cases to Medical Director that require additional expertise.
• Liaisons between third party payors and the treatment team regarding the identified treatment plan in accordance with contractual guidelines or System policy.
• Assists the patient care team with the identification and coordination of alternative treatment settings which will provide appropriate care, maintain quality of care and reduce cost.
• Identifies conditions which require case management across the continuum. Collaborates with the members of the patient care team to identify interdisciplinary needs. Refer to appropriate care management or disease management program.
• Assists with the collection and analysis of utilization patterns and denied cases.
• Brings known or suspected problems of under-, over-, or inappropriate utilization of resources to the attention of the appropriate manager(s).

Common Expectations:

• Prepares and maintains appropriate documentation as required.
• Maintains established policies and procedures, objectives, quality assessment and safety standards.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Prepares and presents utilization data analysis as required.
• Develops and initiates educational programs regarding utilization management principles.
• Attends meetings as required.

Qualifications

Minimum Education:

• Associates Degree Required

Work Experience:

• 3 years Relevant experience. Required
• Experience in utilization management, case management, or clinical nursing specialty. Preferred and
• Working in Human Resources with specific responsibility for leave of absence administration or management. Preferred

Licenses:

• Licensed Registered Nurse Upon Hire Required or
• Registered Nurse Multi State License Upon Hire Required

Benefits Offered (click here for more details):

• Comprehensive health benefits
• Flexible spending and health savings accounts
• Retirement savings plan
• Paid time off (PTO)
• Short-term disability
• Education assistance
• Financial education and support, including DailyPay
• Wellness and Wellbeing programs
• Caregiver support via Wellthy
• Childcare referral service via Wellthy

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