Utilization Management Nurse RN

				Overview:

Collaboration with Managed Care Organizations (MCO) and care providers is vital to ensure care is being delivered in the right setting at the right time.

Responsibilities:

* Collaborate regularly and maintain open communication with leadership, patients, families, internal care givers, and external Utilization Management Nurses.
* Coordinate internal and external health care team activities related to resident care, transitions and discharge planning with agencies, and other healthcare organizations.
* Conduct initial baseline assessment of resident care needs and communicate that effectively to the Managed Care Organization (MCO) ensuring all aspects of care services are communicated accurately.
* Verify all care needs and the authorization for services and outliers.
* Communicate/collaborate with the Managed Care Organization (MCO) at required intervals as determined by the MCO
* Negotiate appropriate levels based on services provided and contractual arrangements with the facility and the MCO.
* Document all authorizations and continued stay activity in Case Management software to ensure appropriate reporting and billing
* Prepare all Managed Care documentation to facility accurate billing.

Qualifications:

* Registered Nurse (RN)  in good standing with required current state license.
* Associates degree required, but Bachelor's degree preferred.
* Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual.
* Minimum of three (3) years related case management experience.
* Minimum of three (3) years of hospital, SNF or Acute Rehab clinical experience
* Certified in Case Management through ACMA, CCMC or other credentialed agencies, preferred or willing to obtain after one year of employment.
* Knowledge of Medicare payment methodology and the MDS RUG system. Previous experience with MDS and assessment preferred
			

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