RN Coordinator Utilization Management (1.0 FTE)

Network Health's success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking a RN Coordinator, Utilization Management who will review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. Reviews applicable guidelines regarding payment and coverage, and makes determinations for authorization/payment.

This nurse will be working specifically with inpatient and skilled nursing facility authorization requests for review and determinations.

This position will be required to work the first two months in office for training. Following successful training, you will be eligible to work remote. Training will occur in the Menasha office location.

Job Responsibilities:

• Evaluates and processes prior authorization requests/referrals submitted from contracted and non-contracted providers.
• Follows 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.
• Provides education regarding utilization management activities and processes to members, caregivers, providers, and their administrative staff.
• Participates in Utilization Management auditing (i.e. Utilization Management Inter-reviewer reliability and denial files).
• Refers 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.
• Collaborates with other NH departments to develop interdepartmental operational processes.
• Supports Utilization Management department programs and goals through active participation.
• Identifies and screens candidates for Case Management intervention and determines appropriate level of care from Utilization Management criteria.
• Completes 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.
• Evaluates cases for cost savings/quality improvement potential.
• Performs 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).
• Experience in insurance, managed care and utilization management preferred.

This position is eligible to work from home in the state of Wisconsin. Candidate must meet the work at home eligibility requirements in order to be considered.

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