RN UM (Utilization Management Nurse) job at Carewise Health in Louisville

Carewise Health is looking of RN UM (Utilization Management Nurse) on Thu, 07 Mar 2013 14:08:46 GMT. 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...

RN UM (Utilization Management Nurse)

Location: Louisville Kentucky

Description: Carewise Health is looking of RN UM (Utilization Management Nurse) right now, this job will be placed in Kentucky. Further informations about this job opportunity kindly read the description below. Essential Functions: -Responsible for the telephonic and fax delivery, of the Utilization Management process to include: assessing, planning, implementing and, coordinating clin! ical 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.-Coordinate quality healthcare services overseeing clinical services provided by homecare vendors or sub-acute facilities, customer service, and competitive pricing. -Serves as a health care coordinator to promote continuity and consistency in the services being provided.-Will conduct an on-going assessment of case and discharge individual from case management services when optimum status has been achieved.-Will conduct an on-going assessment of case! and make plan modifications, as necessary, to achieve patient! goals and improve outcomes.-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 and URAC guidelines.-Responsible for maintaining expected standards developed by the quality/accreditation and compliance department.-Offers suggestions for improvement in the review process.-Maintains a courteou! s 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.-Performs accurate and complete verification of eligibility, benefits, and coverage and apply this information to the pre-certification, discharge planning, and proposal for case management processes inclusive of optimization of benefit usage, PPO redirection and to assist with the research and coordination of funding alternatives.-Other duties as assigned.
Education/Experience Required: -A minimum of three years clinical nursing experience. -Associates degree required, BSN Preferred-Must be able to successfully complete any required pre-employment testing.-Looking for candidate with Waiver experience preferred.Certification Requirements: Unrestricted Active KY RN License
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If you were eligible to this job, please email us your resume, with salary requirements and a resume to Carewi! se Health.

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This job starts available on: Thu, 07 Mar 2013 14:08:46 GMT

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