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Utilization Review Registered Nurse at Mindlance

Utilization Review Registered Nurse

Mindlance Birmingham, AL Full-Time
$58,240.00 - $79,000.00 / year
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Utilization Review RN

Position Summary:

Position:                                 Nurse Case Management Senior Analyst

Location:                                Birmingham, AL/ Nashville, TN

Duration:                                3+ Months (Possibility of Extension)


·         Post-Acute Case Manager RN

·         (Nurse Case Management Senior Analyst/ Band 3)

·         Job Description/Summary

·         The two major functions of the Post-Acute Care Case Manager (PACCM) are to ensure the customer is at the appropriate level of care, and to initiate and follow through in the discharge planning process. Given the complex nature and challenges of the US health system and CMS compliance requirements, it is necessary to provide case management interventions that are flexible, aligned with provider and facility plan of care, and follow the most effective work approaches.

·         Post-Acute Care Case Managers are expected to be able to perform at the top of their license. It is essential that clinically licensed personnel understand health plan benefits, demonstrate good clinical judgment, show initiative and critical thinking skills, and most importantly, follow up and follow through to ensure the best outcome for the customer. 

·         In addition, each Post-Acute Care Case Manager takes an ownership approach in their individual role and responsibilities, and at the same time, understands the value of being a good team member. Client Post-Acute Care Case Managers are one part of a clinical interdisciplinary care team that involves plan physicians and partners, Medical Directors, Community Case Managers, Acute Care Case Managers, Pre- certification nurses, Embedded Care Coordinators (P4Q), and specialists.

·         As with any Client team member the Post-Acute Care Case Manager is a good steward of health plan resources, and consistently represents our company in a positive manner (i.e., follows dress code and demonstrates customer service principles).

Position Scope/responsibilities

·         Attend/present to staff at facility meetings quarterly or as needed.

·         Initiate/update member care plans.

·         Major Job Responsibilities

·         Utilization Management- manages level of care assignments and concurrent review.

·         Medical Director Rounds/Reviews- present complex cases in a clear, concise, and efficient manner.

·         Discharge Planning- perform assessments during admissions to assist with needs post discharge and develop appropriate plan for discharge.

·         Develop and maintain effective working relationships with health plan partners and customers.

·         Maintain compliance with CMS regulatory guidelines regarding determinations.

·         Contribute as an active participant in the company's STAR initiatives

·         Evaluate each case for quality of care, document and report quality issues to the appropriate team.

Other duties as assigned.

·         Perform Health Risk Assessments (HRA) on Special Needs Plan (SNP) customers.

·         Triage customers with an HRA to decide if they need further follow up.

·         Refer high risk customers to case management in the local market

·         Refer customers with Behavioral Health needs to the Enterprise Behavioral Health team

·         Outreach to all customers with an HRA completion to develop a higher level care plan, if needed. 

·         Identify and address customer gaps in care, which may include primary care physician and specialist appointment scheduling.

·         Provide clinical assessments, health education, and community resources to customers, as needed.

·         Identify and develop community resources for customers to include: paying for medications, food, utilities and housing. Local referrals for tax and legal aid.

·         Disease management education for chronic illnesses to include: diabetes, hypertension, CHF, COPD and others.

·         Initiate contact with customer/caregiver/family, primary care physician, and health care providers/suppliers as needed.

Recommended skills

Utilization Management
Disease Management
Case Management
Behavioral Health
Diseases And Disorders
Acute Care
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