Utilization Management - Clinical Nurse - Work from Home!

BroadPath is seeking a highly motivated and results-oriented UM Clinical Nurse to join our team. As the UM Clinical Nurse, you will be responsible for precertification of inpatient hospitalizations and outpatient procedures requiring authorization. Conducts telephonic and concurrent review of hospitalizations and extended outpatient treatments, applying clinical judgment, utilization management principles, and medical necessity criteria while ensuring regulatory compliance.

Analyze clinical information, treatment plans, and regulatory guidelines for authorization requests Apply clinical decision-making to assess acuity and treatment appropriateness Create case summaries for requests not meeting medical necessity criteria and collaborate with medical directors Research clinical guidelines and stay current on Medicaid manual changes Evaluate discharge planning risks and facilitate appropriate continuity of care Meet regulatory timelines for assessments, decisions, and communications Ensure timely processing of all denial determinations according to regulations Document due process and attempt to gather adequate clinical information Notify providers of denials, offering peer-to-peer conversations and communicating appeal processes Distributed denial letters to all involved parties within regulatory timeframes Create compliant communication materials describing decision rationales Hold discussions with providers regarding guideline application and coverage determinations Document all provider interactions in the authorization system Promote provider satisfaction through education on managed care and authorization requirements Serve as liaison between providers and facilities to promote quality service and care Screen and identify potential members for case management programs Recommend care planning based on projected treatment course and prognosis Coordinate with hospital staff on discharge service packages to reduce readmission risk Prepare cost-benefit analyses for exceptional coverage situations Identify potential quality issues, fraud, or abuse concerns Coordinate with UM Analyst staff on appeals and complaints Ensure compliance with regulatory standards and contractual requirements Participate in quarterly inter-rater reliability reviews