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Senior Utilization Management Professional - RN
Ref No.: 18-09056
Location: Richmond, Virginia
Job Title: Senior Utilization Management Professional - RN
Job Location: Richmond, VA
Job Duration: 2 months contract to hire.


Under general supervision, and in collaboration with Medical Directors and other members of the clinical team, gathers and synthesizes clinical information in order to authorize services. Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria; collects and analyzes utilization information; assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity. Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria.

- Develops and manages new enrollee transitions and those involving a change in provider relationships. Develops and implements transition plans, as indicated, to ensure continuity of care. Negotiates and documents single case agreements according to the company's policies and procedures.
- Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria. Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network. As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms.
- In conjunction with providers and facilities, identifies, develops and monitors discharge plans. Collaborates with the Care Coordination Team to implement support for transitions in care. Facilitates timely sharing of enrollees' clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care.
- Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria.
- Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases. Assures that case documentation for each decision is complete, including related correspondence.
- Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis.
- Maintains an active work load in accordance with performance standards.
- Works with community agencies as appropriate.
- Participates in network development including identification and recruitment of quality providers as needed.
- Advocates for the enrollee to ensure health care needs are met. Interacts with providers in a professional, respectful manner.
- Provides coverage of Nurse Line and/or Crisis Line as requested or required for position..

Must have 2 years Utilization post degree Masters clinical experience, and be RN (State and/or Compact State Licensure) Care Management


Typical Day: Review 10+ cases per day from provider facilities such as In-patient, Out-patient, Home Health, etc all through a phone que. There will not be calls from members nor will the selected candidate travel in the field. This business unit services all populations; from pediatrics to geriatrics. They also service a wide variety of medical needs that include Intensive Care, Home Health, Emergency Medicine, etc
What will stand out to the manager: The ideal candidate MUST have utilization experience with a variety of populations in various settings like include Intensive Care, Home Health, and Emergency Medicine. The manager is not looking for someone with Behavioral Health experience only. That's nice to have, coupled with Intensive Care, Home Health and Emergency Medicine. Diversity in reviews will definitely stand out. Care Advance and MCG Criteria experience is a plus.
Something to keep in mind: This is a new contract for Client so the successful candidate will be flexible, open to change, and able to learn as you go.

Hours: 9am – 6 pm, with 1 hour lunch
License: RN (State and/or Compact State License) Care Management
Interviews: In person with the manager and possible with the Team Leaders.