Associate BPM Lead (Utilization Management USRN)

• Review, research, and prepare documentation related to retrospective review requests and appeals in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards.
• Contact appropriate medical and support personnel to identify and recommend an alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
• Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
• May establish care plans and coordinate care through the health care continuum including member outreach assessments.
• Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities.
• Review patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
• Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination as needed.
• Develop and deliver targeted education for the provider community related to policies, procedures, benefits when appropriate.
• This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

Requirements:

• Registered Nurse with current, unrestricted US Registered Nurse license (mainland)
• 3+ years of direct, clinical nursing experience
• 2+ years’ experience in US Healthcare in utilization management or case management
• MCG Certification will be a plus
• Healthedge HRCM or Guiding Care experience is a plus