RN Coordinator Utilization Management

The RN Coordinator Utilization Management reviews submitted authorization requests for medical necessity, appropriateness of care, and benefit eligibility. The RN Coordinator Utilization Management reviews applicable guidelines regarding payment and coverage, and makes determinations for authorization/payment.

Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required). Training is required on-site at our corporate office in Menasha for the first 6-8 weeks. Travel to corporate office will be required occasionally for the position, including on first day.

Hours: 1.0 FTE, 40 hours per week, 8am-5pm Monday through Friday

Check out our 2024 Community Report to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.

Job Responsibilities:

• Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health
• Appropriately apply all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies
• Evaluate and process prior authorization requests/referrals submitted from contracted and non-contracted providers
• Follow Network Health process, policies, and procedures in authorization review of all membership on a pre-service, concurrent, and post-service basis. This process includes verifying eligibility and benefits, as well as documenting all utilization management communication.
• Provide education regarding utilization management activities and processes to members, caregivers, providers, and their administrative staff.
• Participate in Utilization Management auditing (i.e. Utilization Management Inter-reviewer reliability and denial files).
• Refer all members with complex health problems and needs to Network Health Case Management to reduce medical costs while providing a higher quality of life and an ability to take charge of their diseases. This requires an extensive holistic approach to care management assessment
• Collaborate with other Network Health departments to develop interdepartmental operational processes
• Support Utilization Management department programs and goals through active participation
• Identify and screen candidates for Case Management intervention and determine appropriate level of care from Utilization Management criteria
• Complete assessments and plans of care including need for medication regime, treatment plans, practitioner follow-up appointments, knowledge of red flags, disease management, Advance Directives, life planning, and self-management of illness to the best of member ability
• Evaluate cases for cost savings/quality improvement potential
• Perform other duties and responsibilities as assigned

Job Requirements:

• Bachelor of Science in Nursing, preferred
• Associate Degree in Nursing, required
• Minimum of four (4) years clinical health care experience as a Registered Nurse (RN) required
• Experience in insurance, managed care, and utilization management preferred
• Current Registered Nurse (RN) licensure in Wisconsin required
• Proficient skill with MS Office products (Word, Excel, Outlook) preferred

We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.