Job Description

Job Description

Job Description

UNITE HERE HEALTH serves 190,000+ workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!

This is a Nevada Health Solutions (Culinary Health Fund) position

PURPOSE

The Medical Management department is participant focused and strives to provide the best possible care for the participants through Utilization Review and Utilization Management services, Care Coordination and Outreach. The Department is designed to ensure the delivery of high-quality, cost-efficient healthcare for our participants and families through coordinating care, providing detailed discharge plans, advising participants of different programs available and providing face-to-face and telephonic education.

The Utilization Review Nurse is responsible for conducting utilization management activities in accordance with Utilization Management policies and procedures and URAC Guidelines. The position responsibilities include the management of medical costs through timely prospective, concurrent and retrospective review activities. The Utilization Review Nurse promotes exceptional customer service by providing outreach to participant and families as well as providers as providers. The Utilization Review RN position identifies patients who may need additional outreach and works closely with the Health Promotion team to ensure care coordination and outreach is completed.

ESSENTIAL JOB FUNCTIONS AND DUTIES

• Provide Utilization Review within URAC timelines and expectations
• Use critical thinking skills to offer alternatives to care that has been determined not medically necessary
• Redirects care to contracted service providers per guidelines
• Maintains productivity expectations
• Offer education and guidance to patients who may have questions regarding authorization requests
• Contributes to UM program goals and objectives in containing health care costs and maintaining a high-quality medical delivery system through the program procedures for conducting UM activities
• Must become knowledgeable of URAC requirements for clinical staff for UM accreditation
• Performs telephonic review for inpatient and outpatient services using InterQual, Milliman criteria or internal criteria
• Collects only pertinent clinical information and documents all UM review information using the appropriate software system
• Promotes alternative care programs and researches available options including costs and appropriateness of patient placement in collaboration with plan benefits
• Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services
• Communicates directly with the designated medical director regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues
• Recommends, coordinates and educates providers regarding alternative care options
• Participates in UM program activities
• Communicates all UM review outcomes in accordance with the health plan procedures
• Follows relevant time frame standards for conducting and communicating UM review determination
• Maintains and submits reports and logs on review activities as outlined by the UM program operational procedures
• Identifies and communicates all hospital, ancillary provider, physician provider and physician office concerns and issues
• Identifies and communicates all potential quality of care concerns and patient safety
• Serves as liaison for provider staff and the client
• Maintains courteous, professional attitude when working with the Client’s staff, hospital and physician providers, and all ancillary providers
• Identifies and communicate all catastrophic and high risk cases for case management referral
• Active participation in team meetings
• Sets goals and achieve measurable results
• Contributes ideas to plans and achieving department goals
• Demonstrates the Fund’s Diversity and Inclusion (D&I) principles in their conduct at work and contributes to a safe inclusive culture with equitable opportunities for success and career growth
• Exemplifies the Fund’s BETTER Values in contributing to a respectful, trusting, and engaged culture of diversity and inclusion
• Performs other duties as assigned within the scope of responsibilities and requirements of the job
• Performs Essential Job Functions and Duties with or without reasonable accommodation

ESSENTIAL QUALIFICATIONS

Years of Experience and Knowledge

• Two (2) years’ experience in hospital environment or equivalent required
• Minimum 2 years of experience in utilization review, quality assurance, discharge planning or other cost management programs required,
• Minimum two years directly related experience using InterQual or Milliman criteria or healthcare criteria preferred

Education, Licenses, and Certifications

• Unrestricted active RN License in the State of Nevada
• Willingness and ability to obtain a license in other States as may be required by the Fund

Skills and Abilities

• Microsoft Office skills (PowerPoint, Word, Outlook)
• Microsoft Excel skills
• Preferred fluency (speak and write) in Spanish
• Excellent written and verbal communication skills
• Communicate clinical information to non-clinical individuals
• Ability to work collaboratively with multiple departments
• Excellent interpersonal skills – ability to express compassion and balance the emotions with business needs
• Strong communication, documentation, clinical and critical thinking skills essential
• Working knowledge of utilization management required
• Strong problem solving and decisions making skills essential
• Communicate clinical information to non-clinical individuals
• Manage competing deadlines and multiple project in a fast-paced environment

Salary range for this position: Salary: $85,300 - $106,700. Actual base salary may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.

Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week) as a remote opportunity.

We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Short- & Long-term Disability, Life, Pension, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).

#LI-REMOTE

Job Tags

Holiday work, Temporary work, Work experience placement, Flexible hours, Monday to Friday,

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