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Network Health WI · 1 month ago

RN Coordinator Utilization Management

Menasha, Wisconsin, United States

Full-time

Hybrid

Mid Level

4+ years exp

Network Health WI is seeking an RN Coordinator Utilization Management to review authorization requests for medical necessity and appropriateness of care. The role involves evaluating prior authorization requests, providing education to stakeholders, and collaborating with other departments to support utilization management goals.

Financial ServicesFitnessHealth CareInsurance

Responsibilities

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