Utilization Management Registered Nurse

PRN as needed

7:30 am to 4 pm including some weekends

4- or 8-hour shifts

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 complex care management.

Duties and Responsibilities

Essential Functions

• Determines medical necessity, appropriateness of admission, continued stay and level of care using a combination of clinical information, clinical criteria, and third-party information. Refers cases for which criteria are not met to the Medical Director.
• Demonstrates a working knowledge of managed care agreements based on available resources which may include UM Manual, policy and procedure, and facility contract information.
• Identifies areas to improve the cost effectiveness of care while maintaining quality, such as, length of stay, medications, therapies, and diagnostic tests. Liaisons between case management team, third party payors and the treatment team regarding the identified treatment plan in accordance with contractual guidelines or System policy.
• Serves as a liaison between the Medical Director, Physicians, and office staff in resolving authorization questions and issues.
• Educates physicians and staff regarding appropriate level of care and utilization issues.
• 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.

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

• Associate's 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

• Retirement savings plan
• Employee Assistance Program
• Education assistance

For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org)

WellSpan Health’s vision is to reimagine healthcare through the delivery of comprehensive, equitable health and wellness solutions throughout our continuum of care. As an integrated delivery system focused on leading in value-based care, we encompass more than 2,300 employed providers, 250 locations, nine award-winning hospitals, home care and a behavioral health organization serving central Pennsylvania and northern Maryland. Our high-performing Medicare Accountable Care Organization (ACO) is the region’s largest and one of the best in the nation. With a team 23,000 strong, WellSpan experts provide a range of services, from wellness and employer services solutions to advanced care for complex medical and behavioral conditions. Our clinically integrated network of 3,000 aligned physicians and advanced practice providers is dedicated to providing the highest quality and safety, inspiring our patients and communities to be their healthiest.