Utilization Management Nurse

Job Summary:Reporting to the Director of Utilization Management the Utilization Management Nurse is responsible for ensuring that patients receive appropriate cost-effective care by reviewing and evaluating medical services treatments and procedures. This role identifies trends for opportunities to educate and collaborate with healthcare providers patients and specialists to optimize resource utilization and improve patient prospective concurrent and retrospective utilization reviews for medical necessity to ensure treatment and services are appropriate and necessary by reviewing medical records and treatment collaboratively with healthcare providers and Medical Directors to provide guidance on approvals or requests for health plan determination reviews as applicable utilizing CMS clinical guidelines and insurance accurate and detailed records of reviews interventions and communications to ensure adherence to health plan requirements and organizational utilization trends to ensure progress towards organizational goalsEducates healthcare providers and patients regarding appropriate levels of care and service criteria and with Network and specialists to identify opportunities to educate on value-based care resolve specialty gaps by markets improve cost-effectiveness and coordination of care to meet patient Skills/Abilities:Strong knowledge of utilization management functions in value-based care including data analysis claims review reimbursement practices and medical records in-depth knowledge of evidence-based practice legal rules and regulations and best practices in healthcareAbility to effectively leverage business and organizational knowledge within and across functional areasMust possess a high degree of emotional intelligence and integrity driven and focused work ethicContinuous desire to learn and embrace new methods; ability to adapt and be -starter with the ability to think creatively and work effectivelyAbility to build a relationship and work effectively with various seniorities and diverse critical reasoning decision-making and problem-solving skills to make informed decisions and ensure effective resource utilization while maintaining quality patient and ability to travel up to 20%Education and Experience:AA/AS degree in Nursing required; BA/BS degree in Nursing (BSN) or Healthcare Administration preferredA valid active Registered Nurse (RN) license in state(s) of employment requiredA minimum of 3 years current direct utilization management required Work in an acute care facility community-based clinic public health department or specialization with the senior population preferredProficient PC skillsFluency in Spanish or other languages spoken by people in the communities we serve is desirable but not requiredArchWell Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to their race color religion age sex sexual orientation gender identity national origin disability veteran status or any other protected classification.