ISNP Utilization Management Nurse

Brief Description

Join us in transforming healthcare.

At Longevity Health, we're dedicated to advancing healthcare through innovation, compassion, and excellence. We're looking for passionate individuals to join our team and help us make a difference. The individual holding this position is required to support and demonstrate their commitment to Longevity Health’s purpose: To optimize the quality of life of people in long-term care by focusing on their individualized health needs.

Requirements

Key Tasks and Responsibilities:

• Receives requests for authorization of services, including inpatient hospital admissions, outpatient and/or inpatient elective surgery, and referrals for specialty physician consultation with non-participating physician offices. Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination) in the Health Plan designated system accurately and timely.
• Verifies and documents member eligibility for services.
• Communicates and interacts on a real time basis via “live” encounters with providers and appropriate others to facilitate and coordinate the activities of the Utilization Management process(es).
• Utilizes technology and resources (systems, telephones, etc.) to appropriately support work activities. Applies Medical Guidelines for decision making prior to Medical Director/Physician Advisor referral.
• Applies submitted information to Plan authorization process (utilizing Interqual, MCG, NCDs, LCDs or medical guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures). Authorizes services in accordance with medical and health benefits guidelines.
• Coordinates with the referral source if insufficient information is available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows Plan process for requesting additional information.
• Refers cases to Plan Medical Director for medical necessity review when medical information provided does not support the nurse review process for giving an approval of services requested.
• Documents case activities for Utilization determinations and discharge planning coordination in Plan IT system in a real time manner (as events occur). Completes detail line as indicated. Completes ASF per policy.
• Provides verbal/fax denial notification to the requesting provider as per policy. Generates denial letter in a timely manner and saves in the appropriate system defined area.
• Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)
• Submits appropriate documentation/clinical information to clerical support for record keeping and documentation requirements.
• Recognizes opportunities to obtain input from assigned care coordination/Advanced Practice Provider and refers accordingly.
• Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.
• Participates in the appeals process.
• Maintains awareness and complies with Plan authorization timeliness standards based on Health Plan/NCQA requirements.
• Actively participates in weekly review of extended hospital stay members and provides clinical updates and discharge planning needs to the team.
  
  

Supervisory Responsibilities

• There are no supervisory responsibilities for this position.
  
  

Credentials & Coverage

• Licensed as a nurse. Registered Nurse Preferred.
• Valid state driver’s license with a good driving record and proof of automobile insurance required.
• Auto insurance coverage as required by your state of residence. New employees will be responsible for providing proof of coverage prior to hire and on an ongoing basis.
  
  

Education And Training

• Associate’s degree in nursing required, bachelor’s degree preferred.
  
  

Knowledge And Experience

• 3-5 years’ experience as a nurse.
• Minimum of 2 years Health Plan utilization management experience OR equivalent.
• Excellent verbal and written communication skills.
• Excellent computer skills, Clinical Platform/MS Office Products.
• Minimum of one year of supervisory experience in leading a team.
  
  

Summary

Company Overview

Longevity Health is a national provider of Institutional Special Needs Plans (I-SNP), created to meet the complex healthcare needs of nursing home residents. Since our founding in 2018, we've expanded our services across several states and formed strategic partnerships to deliver high-quality, patient-centered care. We are actively growing, with plans to continue expanding our services across the nation.

Longevity Health is an Equal Opportunity Employer. We value diversity and encourage applicants of all backgrounds to apply.

COVID-19 Vaccination Policy

Longevity Health follows federal and state regulations regarding COVID-19 vaccinations. Some facilities may still require staff vaccinations to protect the health of residents. Applicants will be required to provide proof of vaccination, or an approved exemption, where applicable.

If you are passionate about healthcare and ready to help us drive change in long-term care, apply now to join the Longevity Health team!