Community LIFE · 3 weeks ago
Utilization Review Manager (RN)
Pittsburgh, PA
Contract
Onsite
Senior Level, Lead/Staff
$83K/yr - $113K/yr
10+ years expCommunity LIFE is a program of all-inclusive care for the elderly, committed to empowering older adults to remain at home while preserving their dignity, independence and quality of life. The Utilization Review Manager (URM) directs and manages the utilization management functions, ensuring compliance with policies and implementing protocols to support effective care coverage decisions.
Elder CareElderlyHealth CareHospitalMedical
Responsibilities
Direct and manage the utilization management functions of all responsible staff
Develop and implement policies and procedures for utilization management in compliance with established Community LIFE policies and recognized industry standards
Establish and maintain service authorization and utilization management protocols implemented by Utilization Management Coordinators based on medical criteria and necessity
Assure the delivery of the 'right care at the right time in the right location.'
Demonstrate the knowledge and skills necessary to assess, plan care for and provide services to frail elders
Have contract oversight and serve as a liaison with network hospitals, nursing facilities and skilled home health care agencies
Qualification
Required
Bachelor's degree in nursing (BSN) required
License and current registration to practice as Registered Professional Nurse in the state of Pennsylvania
Valid PA driver's license
Minimum of 10 years of experience in a managed care environment with significant experience in the various principles of utilization management (concurrent review, discharge planning, pre-certification) and dealing with long term care clients and/or the frail elderly
Minimum of 5 years of experience in health care administration, medical or case management
Experience in data management and proficiency in analyzing and presenting data in a meaningful way
Ability to analyze, compile, and report data in a meaningful way
Ability to research and develop sound clinical protocols for authorizing inpatient services
Strategic and tactical perspective on how to significantly improve operational performance
Proven experience in creating, implementing and managing care and disease management programs to respond to members' needs and population trends
Ability to interpret and apply guidelines to effectively control medical costs
Proficient verbal and written communication skills
Personal computer skills including spreadsheet, database, and graphics software (Excel, Word, PowerPoint)
Self-organization skills; attentiveness to detail and accuracy
Ability to effectively work independently
Excellent clinical and assessment skills
Thorough knowledge of current acute and long-term care nursing practice and principles of medical management
Ability to plan and coordinate nursing care for individuals, families and groups
Ability to establish and maintain cooperative working relationships
Ability to accept and utilize guidance
Ability to perform duties in accordance with ANA Code for Professional Nurses
Acceptable physical and mental health to carry out the responsibilities of the position
Preferred
MSN preferred
Benefits
Medical, Dental and Vision insurance
Life insurance
Disability insurance
5 weeks Paid Vacation
Paid Holidays
403(b) retirement plan
Tuition Reimbursement
Mileage Reimbursement
Employee Appreciation events
And more!
Company
Community LIFE
Community LIFE is a wellness center that supports elderly and older adult with medical care, home care, palliative care, and geriatric care.
201-500 employees
Funding
Current Stage
Growth StageCompany data provided by crunchbase