Utilization Review Nurse - Remote -id-4903

January 16, 2025

Job Summary

CCCS uses a holistic approach to medical management. The Utilization Management Nurse and the Personal Health Nurse (PHN) works within a team to move the member through the continuum of medical management with the goals of facilitating quality health care through the most cost-effective means. The UMN provides utilization review/pre-certification on various members under designated group contracts.

The PHN performs the Personal Health Management process: assesses the member; work with the member, family and physician to identify problems; establish goals and develop plans of care; coordinate services; educate members; and empower members to independently self-manage and to make knowledgeable health care decisions. Both the UMN and PHN work closely with the provider(s) to ensure that services are provided in the most appropriate setting by the appropriate provider(s).

Additionally, the UMN may interface with clients and CCCS client managers and are responsible for the medical management of designated client(s) in conjunction with PHN’s, client specific and external case managers. All Medical Management Nurses practice within the scope of their licensures.

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Essential Duties And Responsibilities

Include the following. Others may be assigned.

Collecting, analyzing, and evaluating clinical documentation received to determine appropriateness of clinical decisions
Adherence to regulatory and departmental timeframes for review of requests received.
Responsible for the effective and sufficient support of all utilization management activities to include prospective/ pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies.
Using an established set of criteria evaluates, applies and authorizes the medical necessity of inpatient and outpatient services. Referring to medical director when unable to approve a request.
Manages the provision of cost containment services by determining the medical necessity and
appropriateness of setting and treatment, and channeling to network providers.
Uses clinical knowledge and evidence-based criteria to determine the medical necessity of an inpatient admission, treatment plan and goals, identified gaps, risk for readmission or complications and any barriers to discharge
Collaborates with case / disease management departments and vendors to support client contractual agreements, SLA’s, SPD’s to ensure member receives quality care
Supports quality assurance initiatives, quality indicators and performance standards following standard documentation and ERISA / URAC guidelines

Knowledge, Skills, Abilities

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Understanding of CCCS holistic approach to medical management
Understanding of the client’s (customer’s) perspective and needs
Understanding of legislative acts, such as the ADA
Competency in Word
Competency using email, attachments
Excellent verbal communication skills with the ability to communicate with members and communicate professionally with individuals who serve in a variety of functions, i.e. physicians, client managers, customer service staff, CCCS executive management, other CCCS Medical Management nurses, hospital utilization review nurses, etc.
Excellent written communication skills with the ability to write in a professional, business manner
Ability to analyze and resolve complex problems
General understanding of cost containment and how it relates to medical management
Excellent organizational, prioritization, and time management skills
Ability and willingness to function both independently and as part of a team
Understanding of criteria / guidelines to evaluate medical necessity

Education / Experience

Include minimum education, technical training, and/or experience preferred to perform the job.

Bachelor’s degree in a health-related field
Five (5) years of UM/CM experience preferred
Three to five (3-5) years of diverse clinical experience required

Required Certifications/Licensure

Include minimum certification required to perform the job.

RN (Registered Nurse) license required in the state of residence

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Must be able to work in sitting position, use computer and answer telephone
Ability to travel

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Remote Work Environment

TRAVEL

Approximately 0 – 5% travel may be required

ON-CALL

Approximately 25% - 30% weekends and Holiday

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost, and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

Compensation

Compensation and Benefit Information

Pay: $64,168.00 - $96,262.00 annually. Compensation depends on location, qualifications, and experience.
Management level positions may be eligible for sign-on and relocation bonuses.

Benefits

Conifer offers the following benefits, subject to employment status:

Medical, dental, vision, disability, life, and business travel insurance
Paid time off (vacation & sick leave) – min of 12 days per year, accrued accrue at a rate of approximately 1.84 hours per 40 hours worked.
401k with up to 6% employer match
10 paid holidays per year
Health savings accounts, healthcare & dependent flexible spending accounts
Employee Assistance program, Employee discount program
Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.

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Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

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