RN - Utilization Management Nurse - Full Time
Location: Vibra Health Plan - Harrisburg, PA
Vibra Health Plan is Pennsylvania's newest Health Plan focused on the senior population. Our experienced management team is passionate about improving health care quality and access. We're setting the new standard for health insurance plans.
Vibra Health Plan (VHP) is seeking a Full Time Utilization Management Nurse - RN to join our team!
The Utilization Management (UM) Nurse will be a key staff member in the efficient and effective use of medical care resources by the beneficiaries of Vibra Health Plan (VHP). They will work with their team members to ensure that medical care is delivered in an efficient manner using pre-authorization guidelines, medical policy, and concurrent review of cases in both the in and out patient settings. They will use VHP’s claim system to record their findings and interact with VHP’s providers in determining the best use of valuable medical resources.
Perform pre-authorizations on all medical procedures requiring pre-authorization.
Review precertification requests for medical necessity, referring to the CMO those that require additional expertise.
Work with the Customer Service and Patient Advocate Teams to resolve beneficiary issues which may arise from the UM process.
Perform concurrent inpatient reviews of admissions and use InterQual Criteria to assess inpatient status and extending the length of stay as appropriate.
Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:
•Promote improved quality of care and/or life.
•Promote cost effective medical outcomes.
•Prevent hospitalization when possible and appropriate.
•Promote decreased lengths of hospital stays when appropriate.
•Prevent complications in patients under our care when possible.
•Provide for continuity of care.
•Assure appropriate levels of care are received by patients.
Provide appropriate consultation and referral to Case Management personnel.
Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources.
Maintain accurate records of all interactions.
Perform post service reviews of procedures that pend from the QNXT claims system.
Use all current Medicare denial letters appropriately and maintain time frames for notification of UM decisions.
Assist VHP members in understanding their healthcare options.
Establish and maintain communication with patients, families, physicians, and provider systems.
Coordinate and communicate with VHP clinical and customer services.
Complete all required compliance programs and continuous training and education, including department specific requirements such as inter-rater reliability testing.
Performs other related duties as assigned.
Bachelor’s degree in Nursing field required.
2-3 years of UM experience is preferred.
2-3 years of health insurance experience is preferred.
Computer literacy on Microsoft Office products and data base programs required.
Strong organizational and task prioritization skills required.
Demonstrated ability to problem solve complex, multifaceted, emotionally charged situations.
Ability to successfully manage conflict, negotiating "win-win" solutions.
Ability to communicate effectively, both orally and in writing, with groups from diverse backgrounds and technical abilities.
Excellent customer service mentality and experience.
Patient advocacy focus.
Our recruitment team wants to get to know you. Share your passion!
Please complete our online application and submit your resume for immediate consideration.
Thank you for taking the time to consider a career opportunity with our company.
To Apply For This Position:
Resumes can be submitted to Amy Slivinski, Talent Acquisition Specialist.
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