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Utilization Manager RN | AMERIGROUP - Nevada | Las Vegas, NV
Performs technical and administrative work required to evaluate the
necessity, appropriateness and efficiency of the use of medical services
procedures and facilities. Licensed RN responsible for clinical review
of all acute and subacute services for appropriateness based on medical
criteria. This individual is responsible for the management of
healthcare resources necessary and appropriate for achievement of
desired acute and subacute outcomes and the coordination of alternative
levels of care for membership.
PRIMARY RESPONSIBILITIES:
- Performs on-site and/or telephonic review of acute and subacute
services.
- Predicts and plans for patient's needs from pre-admission, through
acute and subacute care and post-discharge, in collaboration with the
member.
- Utilizes pre-approved criteria and guidelines to validate medical
necessity of continued stay and appropriateness of treatment and
discharge planning.
- Acts in conjunction with the appropriate manager(s) on a daily basis
to assess the inpatient census for appropriate alternative health care
service needs.
- Coordinates with appropriate discharge planning team members,
facility utilization management department, physicians and members to
coordinate timely discharges.
- Strives to maintain quality care while effectively utilizing
resources.
- Identifies and reports any quality or utilization issues to the
Medical Director.
- Acts in conjunction with the clinical team related to discharge
planning e.g., home care, hospice care, rehabilitation care, special
program care, transitional care, occupational therapy, speech,
respiratory and physical therapy, durable equipment and disposable
supplies.
- Documents all activities in the appropriate system(s) on a timely
basis.
- Participates in rounds with the Medical Director.
- Review Plan appeal items for concurrent and retrospective reviews as
required and requested.
- Monitors and facilities appropriate utilization of resources
utilizing clinical criteria.
- Tracks and reports trends of inappropriate utilization of resources
to the Medical Director.
- Participates in a multi-disciplinary clinical team to achieve
positive member outcomes.
- Functions as a resource to the clinical team regarding approved
criteria, practice guidelines and alternative treatment options.
- Utilizes effective communication, conflict management and
negotiation skills.
- Utilizes excellent customer service principles to assist internal
and external customers.
- Participates in Quality Improvement Process.
- Maintains member confidentiality.
- Other duties as requested or assigned.
EDUCATION AND EXPERIENCE:
Years and Type of Experience
Required:
- Two years of Utilization Management or Hospital/Acute care experience
required.
- Currently licensed RN with three years experience in health care, case
management, discharge planning, utilization management, or behavioral
health.
- Experience working on the community level and with community agencies
preferred.
Preferred:
Certifications or Licensure
Required:
- Current State RN license
- Certified Professional Utilization Review (as required by Plan)
- Certified Case Managers a plus.
- Must possess a valid driver's license and access to a motor vehicle.
Other Required:
- Computer literate.
- Excellent verbal and written communications skills.
- Strong decision making skills.
- Ability to provide services in an environment that involves multiple
health care systems.
- Ability to interact with all relevant components of the health care
system.
- Ability to provide services that deal with the individual's broad
spectrum of needs.
- Self-starter with ability to handle multiple projects at one time.
- Appreciation of cultural diversity and sensitivity towards target
population.
- Bilingual a plus.
Preferred:
Physical Requirements:
- Must be able to operate a computer.
- Must be able to operate a telephone.
- Must be able to sit for long periods of time.
- Must be able to operate a motor vehicle and travel locally (as
required by Plan).
In accordance with state and federal laws, employment offers are
tendered solely on the basis of qualifications without regard to race,
religion, color, national origin, age, sex, marital status, sexual
orientation, handicap (including disabled veterans) or Vietnam Era
veteran status.
AMERIGROUP administers pre-employment drug testing as a condition of
employment and a satisfactory criminal history background report.
To apply for this position, please copy and paste the following link
into your browser address bar:
http://amerigroup.contacthr.com/13085525
or submit your resume and salary requirements through our homepage at
https://va-psweb.amerigroupcorp.com/psc/agp/APPLICANT/HRMS/c/HRS_HRAM.HRS_CE.GBL?Page=HRS_CE_JOB_DTL&Action=A&SiteId=1&PostingSeq=1&JobOpeningId=1014510145
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