Utilization Management , RN - Remote in WA

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The Utilization Management, RN will serve as the Health Plan subject matter expert for Utilization Management and serve as a key resource for complex and/or critical issues. This position will communicate clinical findings and present rationale for decisions to medical professionals and members at the appropriate level for understanding; and will provide summary clinical and ancillary information to the Health Plan Medical Director for review and decision making, including state fair hearings. If you have a WA RN license (or covered under RN compact licensure), you will have the flexibility to work remotely* as you take on some tough challenges.

Functional role is responsible for utilization management of administrative and IBSS determinations, oversight on outpatient service requests from a reporting perspective and understanding the criteria for inpatient reviews, including concurrent inpatient reviews Leverage experience and understanding of disease pathology (e.g., conditions, normal course of care for a condition) to review chart/clinical information, ask appropriate questions, and identify appropriate course of care in each situation Determines medical appropriateness using medical guidelines and benefit determination Solves complex problems and develops innovative solutions Ability to support and facilitate biweekly meetings for Complex/High Risk members in conjunction with leadership and Health Services staff Provides explanations and information to others on the most complex issues Leverage appropriate clinical terminology when communicating with physicians and other medical professionals Identify inconsistencies or illogical information in patient responses, provider orders or patient history information and take appropriate action Apply professional judgment, take initiative to follow up, and manage conversations to make sound conclusions/recommendations regarding LTSS patient care or coverage Apply information about patient condition and benefit applicability/limitations of coverage to make recommendations Generally, work is self-directed and not prescribed Works with less structured, more complex issues Works with minimal guidance; seeks guidance on only the most complex tasks Coaches, provides feedback, and guides others Acts as a resource for others with less experience Anticipates customer needs and proactively develops solutions to meet them Prepares reports as directed