RN Coordinator Utilization Management

The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable guidelines regarding payment and coverage, and makes determinations for authorization/payment. 

• →Evaluate and process prior authorization requests/referrals submitted from contracted and non-contracted providers
• →Follow Network Health process, policies, and procedures in authorization review of all membership on a pre-service, concurrent and post-service basis. This process includes verifying eligibility and benefits, as well as documenting all utilization management communication
• →Provide education regarding utilization management activities and processes to members, caregivers, providers, and their administrative staff
• →Participate in Utilization Management auditing (i.e. Utilization Management Inter-reviewer reliability and denial files)
• →Refer all members with complex health problems and needs to Network Health Case Management to reduce medical costs while providing a higher quality of life and an ability to take charge of their diseases. This requires an extensive holistic approach to care management assessment
• →Collaborate with other NH departments to develop interdepartmental operational processes
• →Support Utilization Management department programs and goals through active participation
• →Identify and screen candidates for Case Management intervention and determines appropriate level of care from Utilization Management criteria
• →Complete assessments and plans of care including need for medication regime, treatment plans, practitioner follow-up appointments, knowledge of red flags, disease management, Advance Directives, life planning, and self-management of illness to the best of member ability
• →Evaluate cases for cost savings/quality improvement potential
• →Other duties and responsibilities as assigned

• Bachelor of Science in Nursing, preferred
• Associate Degree in Nursing, required
• Current registered nurse licensure in Wisconsin required
• Minimum of four (4) years clinical health care experience as a Registered Nurse (RN) required
• Experience in insurance, managed care and utilization management preferred

Network Health is an Equal Opportunity Employer