Healthcare – Manager – Utilization Management Nurse

Company Information

North American Medical Management (NAMM) provides advanced management services to medical groups seeking to maximize the opportunities of the healthcare delivery network. We specialize in working with physicians, hospitals, payers, patients and employers to successfully manage the delivery of medical services. Our organization has developed sophisticated techniques for managing the revenue and health care expenses of medical groups in the areas of Provider Relations, Health Services, Finance and Operations.

North American Medical Management has a lot to offer those who appreciate our dedication to clinical excellence, innovation and exceptional service. As a national leader in the management of healthcare delivery systems, we provide a professional and supportive environment where our employees feel they are valued and recognized for their contributions to our success.

Job Description

In collaboration with the client physician network and contracted health plans, the Utilization Management Nurse serves as the Health Services Department nurse liaison to the client, pro-actively influencing the appropriate utilization of health care services, while acting as advocate to the patient/family as they receive services throughout the continuum of care. 

• The Utilization Management Nurse performs utilization and case management activities onsite and/or telephonically including inpatient precertification, concurrent and retrospective review; as well as discharge planning.
• The Utilization Management Nurse provides for the complete, accurate and timely processing of utilization and case management data necessary to provide analysis, trending and reporting to the MCO, client PODS and/or Medical Management Committee, and health plan.

Job Responsibilities:

Utilization Management 

• Performs pre-authorization, onsite concurrent review, discharge planning and retrospective review of inpatients as stipulated by the guidelines and procedures outlined by the Health Services Department. 
• Assigns an ELOS for all admissions using Milliman Care Guidelines.
• Collects appropriate clinical information to make a determination of medical necessity for reviewed service based on Milliman Optimum Recovery Guideline and tracks variances.
• Begins the discharge planning coordination process upon admission or precertification.
• Coordinates care with the members’ HMO as required.
• Identifies Institutionalized, ESRD, COB and/or Subrogation cases. Notifies NAMM departments, as appropriate.
• Contributes to department goals and objectives in containing health care costs through the principles of utilization management.

Case Management

• Promotes alternative care programs and researches available options including costs and appropriateness of patient placement.
• Maintains an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital discharge planners, social workers  and the patient’s physician in the early identification of potential home care candidates.
• Recommends, coordinates and educates providers on alternative care options.
• Works collaboratively with ancillary providers to execute agreed upon treatment plan. Coordinates with the HMO as applicable.

Quality Management

• Contributes to department goals and objectives in maintaining a high quality medical delivery system through the principles of quality improvement.
• Collaborates with QI Coordinator to facilitate identification of participants and coordination of services for participants in QI Projects.
• Identifies and presents potential quality issues to appropriate PHO committees for review and recommendations

Data Management        

•  Ensures that all institutionalized patient stays, including retrospective cases and denied cases are completely and accurately recorded and documented in the EZCap system in a timely manner.
• Collects accurate and timely health care data and adequately documents patient related issues, (precert, concurrent review, alternative care, discharge planning, referrals), provider related issues and appropriate use of codes (ICD-9-CM and CPT Codes).
• Maintains appropriate logs identified by the Medical Management Department and monitors weekly for quality assurance of data entry accuracy.
• Prepares and presents Utilization Statistics (i.e., days/1000, referrals, HHC, etc.) to appropriate IPA/PHO committees.

Special Activities

• Works with Provider Relations Representatives by communicating office/provider concerns, needs and expectations.
• Serves as a liaison for PCP/PCP staff and the Health Plan.
• Helps organize, manage and lead various committees and meetings like PODS, Patient Care, and others.
• Performs other duties as requested by the Manager and/or Vice President of the Health Services Department.

• Nurse (RN or LPN) with current license in the state of practice
• BS in Nursing or other health related area preferred
• Minimum three years of experience in utilization review, quality assurance, discharge planning, or other cost management program required, preferably in managed care
• Minimum three years clinical experience, with strong medical/surgical background preferred.

In return for your dedication, we offer competitive salaries and benefits that include medical, dental, vision, 401(k) and 25 PTO per year!

Apply today and explore this exciting opportunity