Utilization Management Specialist Jobs in Pennsylvania

Job Details

The Utilization Management Nurse is responsible assure cost effective, quality utilization management in the acute level of care setting for the pediatric or adult population in the post-acute inpatient setting (i.e., SNF/Rehab). Also, responsible to review clinical information provided by facilities and communicates UM determinations maintaining timeliness.

Work under general supervision of manager and team lead to assure cost-effective, quality patient care management for DME, homecare (acute skilled nursing and therapy services), home infusion, hospice at home, transportation, and Shift care (private duty home health for pediatric medically complex members).

Job Description

• interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
• Review and track emergency admissions to identify appropriate level of care for acute and post-acute inpatient services.
• Perform concurrent review and/or admission review on all hospital admissions using InterQual criteria guidelines.
• Track assigned cases for timely reviews/updates and decisions as reflected in case documentation.
• Request and review medical records to identify appropriate acute care days and approve or refer questionable days to the medical director for decision.
• Function as a liaison between providers, members and interdepartmentally.
• Serve as resource for physicians, PCPs, Utilization Review departments and all medical providers.
• Identify trends that impact on utilization at hospitals during the review process and help resolve them.
• Maintain departmental and regulatory timeframes for utilization decisions.
• Contributes to the development and enhancement of documentation, tracking tools and process flows.
• Maintains collaborative and effective cross-functional training within the Utilization Management Department.
• Utilization management perform after hour’s on-call coverage.
• Participates in relevant work groups and provide deliverables as necessary.
• Successful and timely completion of assignments in accordance with departmental and Company operational objectives and seeks feedback on performance. Ensures that assignments are scheduled and completed in an accurate and timely manner.
• Maintains detailed knowledge of the status of all assignments and routinely updates the manager, as appropriate.
• Responsible to for after hour on call shifts as needed.
• Performs all other duties as assigned.

Education and Experience:

• Graduate of an accredited nursing program (Associate’s or Bachelor’s degree in Nursing).
• BSN preferred.
• Minimum of 2-3 years of clinical nursing experience.
• At least 1 year of utilization management, case management, or managed care experience preferred.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.