Proactively manage inpatient and outpatient utilization to assure that medical care is appropriate, efficient, and medically necessary. Support facility discharge planning efforts, coordination of transition of care and manage utilization through appropriate review of authorization requests.
Analyzes and evaluates medical records and other health data to render medical necessity determinations using specific clinical criteria while adhering to regulatory turn-around times and provide review outcomes to members and providers in accordance with notification standards.
Implements utilization management processes and coordinate medical services with other SelectHealth and Intermountain departments, as well as local, state and federal programs (Medicare, Medicaid, etc.)
Reviews outpatient pre-authorization requests and/or retrospective requests through claims review and incoming requests through fax, electronic authorization platform, or telephone to ensure medical necessity for services requiring pre-authorization.
Proactively and collaboratively interfaces with physicians, internal staff, members and members' families to assist in expediting appropriate discharge, obtain authorizations, and direct toward medically necessary care. Resolves member, family/caregiver assistance requests.
Conducts concurrent reviews for inpatient stays (hospital, Skilled Nursing Facility, Rehab, Long Term Care Hospitals, etc.) and for Home Health agency services. Performs retrospective reviews as needed for services rendered without an authorization.
Coordinates and acts as a resource to the facility Care Management staff in managing transition of care from the facility to alternative level of care. Coordinates with specialty vendors or providers for post-acute care needs.
Contributes to the development and maintenance of policies and procedures to ensure regulatory compliance, identifying new policies and procedures that are required. Complies with all standards pertaining to accreditation (NCQA or other regulatory bodies).
Demonstrates a working knowledge of care management referral criteria, skills related to service, cost evaluation and member satisfaction to effectively identify opportunities and coordinate referrals for care management intervention.
Perform all required documentation and entry into utilization management operating system for authorization and determination.
Contribute to the effectiveness and efficiency of the department. Participate in the documentation of the utilization management program, work plan, and annual evaluation including necessary submission to accreditation or other regulatory bodies.
Participates on a variety of forums to improve department process, opportunities for appropriate cost-containment, and improved member satisfaction.
Demonstrates business management skills related to service cost evaluation, and complies with company policy/procedures/standards.
Consistently adhere to department productivity and performance expectations.
Consistently demonstrates an attitude of customer service excellence to both internal and external customers.
Intermountain Healthcare offers a generous benefits package that contributes to the overall health and compensation of each caregiver.
Various insurance options through Select Health, Intermountain s insurance company
Onsite fitness centers and discounts to local gyms
Live Well caregiver incentive program up to $300 per year
Employee Assistance Program (EAP) including free counseling for caregivers and their immediate family
Over 302,000 discount offers across 10,000 cities on everything from movie tickets, pizza and the zoo to car rentals and hotels
Paid Time Off including but not limited to Parental Leave, Long and Short-Term Disability
401(k) with up to 6% employer contribution
Up to $1,500 referral bonus
Tuition Assistance through Peak - up to $5,200 per year paid to your school as you go.
Current RN license in state of practice.
Three years clinical nursing experience.
One year in Managed Care, Utilization Management, or Case Management.
Basic computer skills including word processing and spread sheets.
Excellent organizational, written, and interpersonal skills and the ability to anticipate and solve problems and communicate clearly and effectively.
RNs hired or promoted into this role need to have or obtain their BSN within three years of hire or promotion.
Bachelor's degree in Nursing (BSN). Education must be obtained from an accredited institution. Degree will be verified.
Current working knowledge of Medicare, Medicaid and Commercial insurance.
Current working knowledge of utilization management and case management techniques.
Working understanding of coding or utilization management criteria (i.e., InterQual, CMS manual).
Ability to work independently, be self-motivated, have a positive attitude, and be flexible in a rapidly changing environment.
Ongoing need for employee to see and read information, assess member needs and view computer monitors.
Frequent interactions with providers, members that require employee to verbally communicate as well as her and understand spoken information, needs and issues accurately.
SelectHealth - Murray
Scheduled Weekly Hours:
The hourly range for this position is listed below. Actual hourly rate dependent upon experience.
$33.38 - $51.19
We care about your well-being mind, body, and spirit which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged. Learn more about our comprehensive benefits package ([ Link removed ] - Click here to apply to Utilization Review Nurse and our commitment to diversity, equity, and inclusion ([ Link removed ] - Click here to apply to Utilization Review Nurse .
Equal Opportunity Employer
Intermountain Healthcare is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.
The primary intent of this job description is to set a fair and equitable rate of pay for this classification. Only those key duties necessary for proper job evaluation and/or labor market analysis have been included. Other duties may be assigned by the supervisor.
All positions subject to close without notice. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, age, national origin, disability or protected veteran status. Women, minorities, individuals with disabilities, and veterans are encouraged to apply.
Thanks for your interest in continuing your career with our team!
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- Claim Processing
- Clinical Nursing
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