Utilization Management RN (Peak Health)

📋 Description

• • Join West Virginia University Hospitals, Inc. as a Utilization Management RN, a pivotal role within our Health Plan's medical management team, dedicated to optimizing patient care and resource utilization.
• • In this remote position, you will collaborate closely with the Medical Director to spearhead initiatives aimed at reducing care variances, ensuring the timely discharge of patients, and effectively referring members to appropriate plan resources to meet their specific care conditions.
• • You will report directly to the Health Plan Manager of Utilization Management, contributing significantly to the strategic direction and operational efficiency of our medical management services.
• • A core responsibility involves assisting in the development and implementation of robust care management review processes, including Prior Authorizations, Predeterminations, Concurrent Reviews, and Retrospective Reviews, all aligned with established industry and corporate standards.
• • You will ensure that all care management reviews are conducted according to accepted clinical guidelines, policies, and established criteria, maintaining the highest level of quality and compliance.
• • Your interventions will be designed to be collaborative, focusing on maximizing each member’s healthcare outcomes and promoting a holistic approach to care.
• • You will play an active role in understanding and refining the Peer-to-Peer Review process, working alongside Medical Directors to continuously enhance member and Provider Network services.
• • A key aspect of this role involves educating both internal and external stakeholders and partners, fostering stronger relationships and driving continuous process improvements across the network.
• • You will work in close partnership with other members of the medical management team to proactively identify members whose healthcare outcomes could be significantly enhanced through targeted coaching and/or case management interventions.
• • A commitment to understanding the data collected within this position is essential, and you will collaborate with team members to analyze this data and identify opportunities for improving overall outcomes.
• • This role demands a dedication to lifelong learning and a proactive approach to the continuous improvement of processes within the realm of Utilization Management.
• • You will leverage your clinical expertise to assess patient needs, review medical records, and apply evidence-based criteria to determine the appropriateness of care.
• • The position requires a thorough understanding of healthcare regulations, including federal and state laws, NCQA standards, and industry best practices related to disease management, utilization management, case management, and discharge planning.
• • You will be instrumental in facilitating communication between providers, patients, and insurance payers, ensuring clarity and efficiency in the authorization and review processes.
• • This role offers the opportunity to make a tangible impact on patient care by ensuring they receive the right care, at the right time, in the right setting.
• • You will contribute to the financial health of the organization by promoting efficient resource allocation and preventing unnecessary healthcare expenditures.
• • The remote nature of this position offers flexibility and the ability to work from a home-based office, contributing to a healthy work-life balance.
• • You will be part of a dynamic and supportive team, dedicated to achieving excellence in healthcare management.
• • This role is ideal for a Registered Nurse with a passion for improving healthcare systems and a strong understanding of clinical pathways and managed care principles.
• • Your ability to navigate complex healthcare systems and advocate for patient needs will be crucial to your success.
• • You will be expected to maintain meticulous documentation and adhere to all compliance and regulatory requirements.
• • The position involves staying abreast of evolving healthcare policies and industry trends to ensure best practices are consistently applied.
• • You will contribute to a culture of quality improvement and patient advocacy within the organization.
• • This role is critical in ensuring that West Virginia University Hospitals, Inc. continues to provide high-quality, cost-effective healthcare services to its members.
• • You will be a key player in managing the continuum of care, from initial assessment to discharge planning and post-acute care referrals.
• • The collaborative environment encourages knowledge sharing and professional development, offering opportunities to expand your expertise in utilization management and healthcare administration.
• • Your insights and contributions will directly influence patient care pathways and operational strategies.
• • This position is designed for a proactive and detail-oriented RN who thrives in a remote work setting and is committed to making a difference in healthcare delivery.
• • You will be an integral part of a team that values innovation, collaboration, and a patient-centered approach to care management.
• • The role requires a strong understanding of clinical decision support tools and the ability to apply them effectively in daily practice.
• • You will contribute to the overall mission of West Virginia University Hospitals, Inc. by ensuring efficient and effective utilization of healthcare resources.
• • This is an exciting opportunity to leverage your nursing expertise in a dynamic managed care environment, contributing to improved health outcomes for a large member population.