Job Description: Proactively manage inpatient and outpatient utilization to assure that medical care is appropriate, efficient, and medically necessary. Support facility discharge planning efforts, coordination of transition of care and manage utilization through appropriate review of authorization requests.Job EssentialsAnalyzes and evaluates medical records and other health data to render medical necessity determinations using specific clinical criteria while adhering to regulatory turn-around times and provide review outcomes to members and providers in accordance with notification standards.Implements utilization management processes and coordinate medical services with other SelectHealth and Intermountain departments, as well as local, state and federal programs (Medicare, Medicaid, etc.)Reviews outpatient pre-authorization requests and/or retrospective requests through claims review and incoming requests through fax, electronic authorization platform, or telephone to ensure medical necessity for services requiring pre-authorization.Proactively and collaboratively interfaces with physicians, internal staff, members and members' families to assist in expediting appropriate discharge, obtain authorizations, and direct toward medically necessary care. Resolves member, family/caregiver assistance requests.Conducts concurrent reviews for inpatient stays (hospital, Skilled Nursing Facility, Rehab, Long Term Care Hospitals, etc.) and for Home Health agency services. Performs retrospective reviews as needed for services rendered without an authorization.Coordinates and acts as a resource to the facility Care Management staff in managing transition of care from the facility to alternative level of care. Coordinates with specialty vendors or providers for post-acute care needs.Contributes to the development and maintenance of policies and procedures to ensure regulatory compliance, identifying new policies and procedures that are required. Complies with all standards pertaining to accreditation (NCQA or other regulatory bodies).Demonstrates a working knowledge of care management referral criteria, skills related to service, cost evaluation and member satisfaction to effectively identify opportunities and coordinate referrals for care management intervention.Perform all required documentation and entry into utilization management operating system for authorization and determination.Contribute to the effectiveness and efficiency of the department. Participate in the documentation of the utilization management program, work plan, and annual evaluation including necessary submission to accreditation or other regulatory bodies.Participates on a variety of forums to improve department process, opportunities for appropriate cost-containment, and improved member satisfaction.Demonstrates business management skills related to service cost evaluation, and complies with company policy/procedures/standards.Consistently adhere to department productivity and performance expectations.Consistently demonstrates an attitude of customer service excellence to both internal and external customers.Posting Specifics
Entry Rate: Depending on experience
Benefits Eligible: Yes. Click here (https://intermountainhealthcare.org/careers/working-for-intermountain/employee-benefits/) to check out our benefits
Shift Details:Monday – Friday Days shifts between 9:00am and 5:30pm
Department: Healthy Connections Medicare - Select Health
Other: Remote work, needs to be able to come into Murray, Utah office at least quarterly
Minimum Qualifications
Bachelor's degree in Nursing (BSN). Education must be obtained from an accredited institution. Degree will be verified.
Current RN license in state of practice.
Three years clinical nursing experience.
One year in Managed Care, Utilization Management, or Case Management.
Basic computer skills including word processing and spread sheets.
Excellent organizational, written, and interpersonal skills and the ability to anticipate and solve problems and communicate clearly and effectively.
Preferred Qualifications
Current working knowledge of Medicare, Medicaid and Commercial insurance.
Current working knowledge of utilization management and case management techniques.
Working understanding of coding or utilization management criteria (i.e., InterQual, CMS manual).
Ability to work independently, be self-motivated, have a positive attitude, and be flexible in a rapidly changing environment.
Physical Requirements: Ongoing need for employee to see and read information, assess member needs and view computer monitors.
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Frequent interactions with providers, members that require employee to verbally communicate as well as her and understand spoken information, needs and issues accurately.Anticipated job posting close date: 05/27/2024Location: SelectHealth - MurrayWork City: MurrayWork State: UtahScheduled Weekly Hours: 40The hourly range for this position is listed below. Actual hourly rate dependent upon experience. $38.83 - $57.46We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged. Learn more about our comprehensive benefits packages for our Idaho, Nevada, and Utah based caregivers (https://intermountainhealthcare.org/careers/working-for-intermountain/employee-benefits/) , and for our Colorado, Montana, and Kansas based caregivers (http://www.sclhealthbenefits.org) ; and our commitment to diversity, equity, and inclusion (https://intermountainhealthcare.org/careers/working-for-intermountain/diversity/) . Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.Intermountain Health is a Utah-based, not-for-profit system of 33 hospitals (includes "virtual" hospital), a Medical Group with more than 3,800 physicians and advanced practice clinicians at about 385 clinics, a health plans division called Select Health, and other health services. Helping people live the healthiest lives possible, Intermountain is widely recognized as a leader in clinical quality improvement and efficient healthcare delivery.Join our world-class team and embark on a career filled with opportunities, strength, innovation, and fulfillment.To find out more about us, head to our career site here (https://intermountainhealthcare.org/careers/?utmsource=Workday&utmmedium=Redirect&utmcampaign=CareerHomeworkday) . Sign up for job alerts! Click ‘sign in’ at the top right corner, create a candidate account, and when we have opportunities that meet your interests, you will receive an email with the job details.Intermountain Health strives to make the application process accessible to all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact 1-800-843-7820 or email [email protected] . This contact information is for accommodation requests only and cannot be used to inquire about the status of applications.We intentionally work toward an Intermountain Health that reflects our diverse communities and provides culturally competent care, health equity, and a sense of belonging amongst all our caregivers (employees). This is an important part of fulfilling our mission to help people live the healthiest lives possible. The three pillars of our work are talent experience with Intermountain (application, internship, development, etc.), community benefit, and care delivery.Learn more about diversity at Intermountain, here. (https://intermountainhealthcare.org/careers/working-for-intermountain/diversity/) Introduce yourself to our Talent Acquisition team and we will get in touch if there is a role that seems like a good match.Intermountain Health’s PEAK program supports caregivers in the pursuit of their education goals and career aspirations by providing up-front tuition coverage paid directly to the academic institution. The program offers 100+ learning options to choose from, including undergraduate studies, high school diplomas, and professional skills and certificates. Caregivers are eligible to participate in PEAK on day 1 of employment. Learn more. (https://intermountainhealthcare.org/careers/working-for-intermountain/employee-benefits/peak-program/) The primary intent of this job description is to set a fair and equitable rate of pay for this classification. Only those key duties necessary for proper job evaluation and/or labor market analysis have been included. Other duties may be assigned by the supervisor.All positions subject to close without notice.Thanks for your interest in continuing your career with our team!