Utilization Management Nurse

Company Overview

Associated Care Ventures, Inc. (ACV) is the Birmingham-based parent company of Simpra Advantage, Inc., an Alabama domiciled insurance company operating an Institutional Special Needs Plan, a Dual Eligible Special Needs Plan, and an Institutional Equivalent Special Needs Plan. ACV is the parent company of Alabama Select Network, LLC, which is operating an Integrated Care Network for the Alabama Medicaid Agency, to coordinate Medicare and Medicaid services state-wide for eligible individuals receiving long term services and supports, both living at home and in nursing facilities.

Position Summary

The Utilization Management Nurse is directly responsible for ensuring that authorization requests, provider and member clinical inquiries are processed timely accordingly to CMS guidelines and handled appropriately within member’s plan benefits coverage and established clinical guidelines utilized for appropriate clinical decision-making.

Role/Responsibilities:

• Processes prior authorization and retrospective requests, by evaluating the medical necessity of requests submitted by providers by utilizing InterQual® criteria, Medicare National Coverage Determination (NCD) or Medicare Local Coverage Determination (LCD) guidelines, or internally developed clinical criteria, collaborating, as necessary, with facility-based Nurse Practitioners, Care Management staff and Medical Directors.
• Evaluates the medical necessity of continuing acute inpatient stays and acute rehabilitation and skilled nursing stays utilizing InterQual® criteria.
• Collaborates with facility staff, member’s PCP, Plan Medical Directors, facility-based Nurse Practitioners, Care Management staff, and others regarding management of members not meeting continuing stay criteria.
• Anticipates member’s post-discharge needs, managing transition of care or referring to Care Management, per Plan policy and procedure.
• Completes member and provider notifications, citing clinical criteria and Medical Director denial rationale, when indicated.
• Maintains mandated timeframes, including those related to fast-track appeals, and quality standards.
• Maintains current knowledge of medical necessity criteria, Medicare guidelines, the Plan’s covered benefits, and the Plan’s utilization related policies and procedures, etc.
• Collaborates regularly with the UM Leadership team, Plan Medical Directors, facility-based Nurse Practitioners, Care Management team members, members’ PCPs, requesting providers, and facility care management staff.
• Identifies opportunities for improvement; collaborates with UM Leadership, facility-based Nurse Practitioners, Care Management team, including CM Leadership, and others to implement approved changes.
• Collaborates with Plan operations team regarding impact of utilization management policies and procedures on other operational areas, such as Claims; participates in interdepartmental meetings, as requested.
• Identifies opportunities for process and policy improvement.
• Other duties as assigned.

Education, Skills, & Knowledge - Qualifications & Experience

Education and Experience requirements

• Nursing degree or diploma required; Bachelor’s Degree in Nursing (BSN) preferred
• Certified Coding Professional (CPC) or other medical coding certification desirable
• 5 years Registered Nurse experience, including 2 years direct care services and 3 years of any combination of utilization management, discharge planning in an acute care setting or care coordination.
• 2 years’ experience with pre-authorization, utilization review/management, case management, care coordination, and/or discharge planning; experience with Medicare guidelines.
• Health plan operations, experience interacting with providers highly desirable
• Experience in Medicare-SNP programs is preferred

• Registered Nurse (RN) - Active, current, and unrestricted Alabama License

Specialized Skills/Knowledge

• Strong oral and written communication skills
• Ability to interact within all levels of the organization as well as with external parties
• Strong working knowledge of Microsoft Office products.
• Demonstrated organization and time management skills· Strong analytical and clinical problem solving
• Ability to prioritize work
• Detail oriented
• Strong understanding of HIPAA and other applicable regulatory requirements.

Compensation

Salary will be commensurate to length and complexity of experience in Utilization Management Nurse roles. Salaried position provides full benefits package, including but not limited to BCBSAL health insurance, 401k, paid vacation, and personal days.

Job Type: Full-time

Pay: $72,000.00 - $82,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Work Location: Remote

Salary : $72,000 - $82,000