The RN is responsible for performing utilization reviews and medical necessity assessments for group health plan members. This includes coordinating treatment plans, providing patient education, and ensuring compliance with HIPAA and URAC standards.
Imagine360 is seeking a Utilization Management, RN to join the team!
The RN Utilization Management Nurse is responsible for providing utilization review/notifications and education for individuals under the group health plans administered by imagine360 by utilizing nursing education, clinical, and professional experience.
The Registered Nurse will practice within the scope of practice while performing assessments, coordination, planning, monitoring and evaluation.
Position Location: 100% remote Responsibilities include but are not limited to: Perform all tasks in accordance with Department of Labor, HIPAA, ERISA and Care 360 department Policy and Procedures.
Complete HIPAA and URAC training annually.
Identify, collect, process and manage data to complete reviews for Medical Necessity per imagine 360 approved clinical guidelines.
Accurate utilization and documentation in appropriate software including time slips in CaseTrakker to complete and document the review process per Care 360 Policy and Procedure.
Provide oversight to non-clinical staff members regarding interpretation of clinical data.
Consult with Care 360 Physician Advisor or peer reviewer per policy and procedures.
Assess and review current treatment history to identify appropriate referrals to Case Management Program or other Care 360 Services.
Communicates professionally and effectively as needed with members, physicians, other healthcare professionals, peers, Supervisor of UM to complete the utilization process per Care 360 Policy and Procedures.
Utilize clinical knowledge, expertise and imagine 360 approved educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures and/or treatment.
Attend scheduled and periodic meetings, training and other job specific events as required either by teleconference or onsite.
Participate in the Quality Management program of the organization by completing the Quality Assurance review process and other procedures per policy and procedure.
Work regular scheduled hours and be available for additional coverage outside of normal working hours as needed.
Evaluating clinical data.
Assessment and evaluation of the acquired clinical data to assess for appropriateness of treatment plan based upon imagine 360 clinical guidelines.
Coordination of treatment plans, interventions and outcomes measurement.
Rationale for the effects of medication and treatments.
Provide patient education and educational resources.
Accurately report: Administration of medication and treatments Client response Contact with other health care team members Respect the client's right to privacy by protecting confidential information.
Promote and participate in education and counseling to a participant based on health needs.
Clarify any treatment that is believed to be inaccurate, non-effacious, or contraindicated by consulting with appropriate practitioner.
Other duties as assigned.
Required Experience/Education: Nursing Degree from an accredited college or university and an active, current, and unrestricted Registered Nurse License in eNLC compact state Bachelors degree preferred 1+ year in Utilization Management and/or Case Management experience Experience in utilization review services preferred.
Experience and knowledge of CPT and ICD coding preferred.
Skills and Abilities: Ability to read and interpret documents such as HIPAA compliance, safety rules, operating and maintenance instructions, and policy and procedure manuals.
Ability to write routine reports and correspondence.
Ability to speak effectively to members and employees.
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages.
Ability to apply concepts of basic mathematics and fundamental accounting principles.
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.
Ability to deal with problems and exercise sound judgment involving several concrete variables in standardized situations.
To perform this job successfully, an individual must have basic knowledge and skills using Microsoft Office Word, Internet software, and Database software.
License and Certifications: Current, active, and unrestricted compact Registered Nurse license.
Must maintain CEU's as required by the State Board of Nursing.
Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization.
Current Certified Case Manager (CCM) Certificate preferred; if Certification is not current, employee must pursue and achieve CCM Certification within three years of employment.
What can Imagine360 offer you?
Multiple Health plan options Company paid employee premiums for disability and life insurance Parental Leave Policy 20 days PTO to start / 10 Paid Holidays Tuition reimbursement 401k Company contribution Company paid Short & Long term Disability plus Life Insurance Professional development initiatives / continuous learning opportunities Opportunities to participate in and support the company's diversity and inclusion initiatives Want to see our latest job opportunities?
Follow us on LinkedIn Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise.
Over the years, we've helped thousands of employers save billions on healthcare.
Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.
Imagine360 is an equal opportunity employer.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. **RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role.
Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable.
Thank you for your cooperation**
Requires a Nursing Degree and an active, unrestricted Registered Nurse License in an eNLC compact state. Candidates should have at least one year of experience in Utilization or Case Management, with a Bachelor's degree and CCM certification preferred.
