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Job Description

Description

NOTE: THIS POSITION HAS THE ABILITY TO WORK REMOTELY UNTIL FURTHER NOTICE!

Innovista Health Solutions is an Illinois-based service organization with management services operations in Illinois and Texas. We are currently looking for a Utilization Management Nurse reporting out of our Oak Brook, IL office. At Innovista, we believe that positive forward movement in today’s uncertain healthcare market stems from the combination of innovative programs and dedicated people. Join the Innovista team and lead the charge to a better, more efficient healthcare system.


JOB SUMMARY:

Provide internal support to the Medical Management Department in the areas of Inpatient and Outpatient utilization management ensuring that all services referred meet plan and client requirements adhering to approved criteria.

DUTIES AND RESPONSIBILITIES:

  • Fully understands policies, procedures and operations of Innovista Health Solutions.
  • Effectively communicates in a timely manner to management and internal departments.
  • Conducts Pre-certification of all elective admissions with the Health Plan or other certifying entity.
  • Receives notification of admissions and maintains admission logs.
  • Maintains compliance with all Health Plan guidelines on the reporting of cases/surgeries.
  • Understands Health Plan policies and procedures regarding pre-certification, benefits by health plan and preferred facilities within each plan.
  • Performs inpatient utilization review and applies client guidelines as detailed in the client UM Plan for length of stay/admission criteria to approve initial and continued inpatient services.
  • Requests relevant clinical information and documents in operating system.
  • Determines appropriate level of care and place of service based on medical information available and criteria application.
  • Facilitates discharge planning of members.
  • Arranges needed post-acute discharge services such as; DME, Home Health, Skilled Nursing
  • Coordinates complicated medical cases and retrospective requests with Medical Directors.
  • Assists referral coordinators in medical necessity determinations of referrals.
  • Identifies and refers Members who would benefit from case management services.
  • Coordinates the collection of appropriate documentation to assist with quality projects and enters data using appropriate software.
  • Is supervised by a licensed professional nurse or physician
  • This position may include rotations of telephonic after-hours, on-call duties
  • Other duties as assigned.

Requirements

  • Associate or Bachelor of Science degree (AND or BSD) in Nursing, required or equivalent experience required.
  • A minimum of 3 years of clinical experience in a hospital, LTAC, skilled nursing facility, home health/hospice or physician office setting. 
  • At least 3-4 years of relevant professional experience, including medical management experience in health plans, provider, or MSO settings and quality chart reviews.
  • Registered Nurse (RN) with a current and active nursing license to practice in the State assigned required.
  • Certified Case Manager (CCM) preferred.
  • Knowledge/experience in Medicare/Medicaid and HEDIS criteria is highly desirable.
  • Knowledgeable in InterQual and/or MCG(Milliman).
  • Demonstrate excellent organizational skills.
  • Demonstrate effective verbal and written communication skills.
  • Demonstrate analytic skills when problem solving.
  • Proficient in MS Office Applications and ability to learn department and job specific software systems.
  • Demonstrate attention to detail and a high degree of accuracy.
  • Able to commit to Innovista’s corporate mission and values.
  • Able to switch priorities in a positive and effective manner when directed by Company leadership.                       
  • Able to effectively communicate technical concepts with team members and basic business concepts with team members and internal customers.  
  • Valid Driver’s License and vehicle required, Ability to travel at least 30% for client meetings within the state required.
  • Eligible for consideration of partial work from home status upon completion of probationary period as designated by the direct supervisor.

BENEFITS:

Innovista is dedicated to hiring passionate individuals who embody our core values: integrity, determination, and teamwork. We recognize the importance of work-life integration and seek to provide our employees with competitive benefits, which include:

  • Comprehensive health plan options, dental, and vision coverage subsidized by Innovista
  • Opportunity to work from home, based on position and manager discretion
  • Company-paid benefits, such as short- and long-term disability, employee life, and AD&D
  • Discretionary bonus
  • 401(k) with company match
  • Opportunity for career advancement and growth
  • Flex time options may be available
  • Please note: we do not post salary ranges. Salary ranges posted on other sites are not tied to our labor market specifications and are not relevant.

Company Overview

  • Website innovista-health.com
  • Headquarters WESTCHESTER, IL
  • Size 100 - 200
  • Founded 2013
  • Type Private
  • CEO JAY MYERS
  • Revenue <$5M
  • Industry Business Services
  • About innovista health solutions

Skills for UM Nurse

The job skills required for UM Nurse include home health, Outpatient, Communicates Effectively, Written Communication, Integrity etc. Having related job skills and expertise will give you an advantage when applying to be an UM Nurse. That makes you unique and can impact how much salary you can get paid. Below are job openings related to skills required by UM Nurse. Select any job title you are interested in and start to search job requirements.

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Career Path for UM Nurse

The following is the career advancement route for UM Nurse positions, which can be used as a reference in future career path planning. As an UM Nurse, it can be promoted into senior positions as a Clinical Outcomes Manager that are expected to handle more key tasks, people in this role will get a higher salary paid than an ordinary UM Nurse. You can explore the career advancement for an UM Nurse below and select your interested title to get hiring information.