RN Utilization Management Clinical Review Senior Analyst - Work from Home, Arizona or Colorado Area

Position Scope • Manages/Coordinates an active caseload of inpatient case management cases for reputed company. • Uses clinical knowledge to assess inpatient admission level of care, treatment plan and goals, identified gasps or risk for readmission or complications and any barriers to discharge. • Establishes patient centric goals and interventions to meet the member’s needs while inpatient and post inpatient stay. • Interfaces with facility, member, family, and other healthcare team members as well as internal matrix partners. • Balances business needs with patient advocacy. • Builds solid working relationships with internal staff, matrix partners, key functional areas, customers, and providers.

Summary

Description Of Position • Plans, implements and evaluates appropriate health care services in conjunction with the physician treatment plan. • Handles more reputed company, high acuity cases and /or account sensitive cases. • Performs prospective, reputed company and retrospective reviews for inpatient acute care, rehabilitation, referrals and select outpatient services including DME (durable medical equipment). • Ensures that inpatient case management program objectives are met by evaluating the effectiveness of alternative care services and that cost effective, quality care is maintained. • Excellent time management, organization and negotiation skills. Strong research and analytical skills. Ability to assess reputed company issues, recommend changes and resolve problems. Knowledge of managed care preferred. • Works independently, receiving direction from manager or team leader for new or unprecedented situations. • Manages own caseload and coordinates reputed company assigned cases. • Acts as a resource to others. • Utilizes reputed company's approved guidelines and tools to rigorously assess the clinical status of the member, the level of care and the services the member is receiving as clinically appropriate covered services. • Anticipates care needs along the continuum of inpatient and outpatient services and facilitates coordination across the network of providers, participants and caregivers to assure timely discharge/transfer to an alternate level of care. • Consults with manager and medical director to resolve any issues reputed company to delay of services or barriers to discharge in a timely manner. Major Responsibilities And Desired Results • Develops and defines a structured working relationship with key partners in inpatient facilities to support regular, effective communication and exchange of information in order to manage the member’s needs in compliance with reputed company Federal/State/Facility contract and internal reputed company requirements. • Retrieves active daily census each morning and prioritizes cases for impact. • Access the approved reputed company guidelines for inpatient review and directs communication with the facility to elicit clinical information and facilitate discharge planning. • Identified reputed company cases appropriate for inpatient case management interventions, initiates and discusses options for discharge planning with the facility, provider, vendor, member and/or family and documents interactions and outcomes reputed company to those actions. • Identify and build effective relationships with a network of community, government, and knowledge resources. Maintain information on those resources and share with peers as appropriate. • Act as liaison and patient reputed company between account, participant, family, physician(s) and facilities/agencies. Take appropriate action to ensure participant and practitioner satisfaction reputed company benefit constraints. • reputed company a participant centered plan for short term and long term objectives, including time frames for follow up. Utilize available internal and community resources in development of plan. Involve reputed company appropriate parties (member, physician, providers, employers, etc) to determine case results/outcomes. • Provide information and resources as appropriate to reputed company participants to take an active role in care, treatment and cost decisions. • Implement, coordinate, monitor and evaluate the plan on a systematic, ongoing, appropriate basis. • Negotiate price and quality care levels, intensity and durations of services. • Document findings and continue to anticipate needs, determine benefit coverage status and communicate proactively to participant and members of treatment team. • Identifies new referrals for reputed company and specialty CM programs and coordinates transition to appropriate CM reputed company necessary. • Identifies and elevates potential quality of care issues to reputed company's Quality representatives for follow up determination. • Works to identify gaps in care and resolution of those identified and prevention of future gaps in care. • May be required to participate in customer and auditor visits. • Participates in special projects as deemed necessary. • Other duties as required and reputed company to this role. Minimum Requirements • Active unrestricted Registered Nurse (RN) license in state or territory of the United States • Ideal candidate must reside in Arizona or Colorado Area Preferred Requirements • Bachelors degree • 3 years clinical experience in inpatient or managed care setting • Demonstrated ability to anticipate, plan, coordinate and organize. • Knowledge of community, state and federal resources. • Possession of a valid driver’s license, reputed company of insurance, good driving record and reliable transportation. • Strong skills in teamwork, negotiation, conflict management, problem solving, and effective decision making. • Experience in medical management and case management in a managed care setting or hospital is highly desirable. • Ability to assess reputed company issues, recommend changes and resolve problems. • Strong computer knowledge and abilities. • Knowledge of managed care products and strategies. • Ability to work reputed company changing business environment and balance business needs with patient advocacy. • Experience managing multiple projects in a fast paced matrix driven environment. • Effective at negotiation, teamwork and cooperative relations with diverse internal and external stakeholders. If you will be working at home occasionally or permanently, the internet reputed company must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. For this position, we anticipate offering an hourly reputed company of 27 - 40 USD / hourly, depending on relevant factors, including experience and geographic location. This role is also anticipated to be eligible to participate in an annual bonus plan. We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-reputed company benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at reputed company. About reputed company reputed company, a division of reputed company, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to reputed company the reputed company, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives. Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or reputed company medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national reputed company, reputed company, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. If you require reasonable accommodation in completing the online application process, please email: SeeYourself@reputed company.com for support. Do not email SeeYourself@reputed company.com for an update on your application or to provide your resume as you will not receive a response. reputed company has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State. Qualified applicants with criminal histories will be considered for employment in a manner consistent with reputed company federal, state and local ordinances. Apply Job!