Carewise Health helps organizations improve the personal health of employees and control healthcare costs. Our industry-leading health and wellness programs help members build the skills they need to achieve and sustain optimum health. Medical Bill Review ensures that health plans and self-insured employers are billed accurately for the care their members receive. Headquartered in Louisville, Ky.
This RN UM position is classified as remote. ** There may be a rare occasion that a review/audit would be required on-site at a facility in Kentucky. **
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.
Carewise Health provides a generous benefits package including:
Medical Insurance
Dental Insurance
Life Insurance
Vision Insurance
Paid Vacation
Paid Holidays
Paid Sick Days
Short Term Disability
Long Term Disability
401K Plan With Company Match
Tuition Reimbursement
Employee Assistance Program
All benefits are effective on the first day of employment with the exception of tuition reimbursement and STD/LTD, which is effective 90 days of employment.
Attention Staffing Agencies: This position is not open for agency submittals. Any candidate submitted without HR approval will be considered an applicant of Carewise Health, not the agency. All Agency Candidates must first be submitted to HR.
If you are interested in applying for employment with Carewise Health and need special assistance or an accommodation to apply for a posted position, call 1-800-492-6398 (option 1) to leave a message with your requested accommodation.
EOE Disability/Veterans
Required Skills
-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.
Required Experience
-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 working with individuals with complex care needs 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.
Qualifications:
-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.