Case Manager- Utilization Review

Description:

Utilization Review Nurse perform integrated case management (CM) and disease management (UM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members' care including clinical nurses and treating physicians. Care Managers determine, develop and implement a plan of care based on accurate and comprehensive assessment of the member's needs. Care Managers apply detailed knowledge of established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.

Responsibilities:

• Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the member's needs.

• Applies detailed knowledge of FEP PPO established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.

• Works with complex cases, promotes the delivery of quality; cost-effective health care services based on medical necessity and contractual benefits.

• Provides guidance to the provider network via telephone triage.

• Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care via phone/ computer work.

• Makes referrals to Quality Management, Catastrophic Case Management and Appeals and Grievance Department via computer and virtual meetings.

• Screen enrollees for initiatives and programs including Case Management and Disease Management

• Use judgment in selecting appropriate guidelines

• Apply general policies and procedures

• Interface with patients, doctors, and other nurses regarding the status of patient care

• Suggest changes to patient care methods or facilities

Skills:

Acute care, acute, nurse, clinical, healthcare, Case management, Utilization management, Utilization review, Insurance

Top Skills Details:

Acute care, acute, nurse, clinical, healthcare, Case management

Additional Skills & Qualifications:

• Bachelor' s of Science in Nursing or advanced degree preferred. • Active Oklahoma RN license required. • Case Manager, Discharge Planner, UR experience. • Utilization review experience in a facility

Experience Level:

Intermediate Level

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

Diversity, Equity & Inclusion

At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

• Hiring diverse talent

• Maintaining an inclusive environment through persistent self-reflection

• Building a culture of care, engagement, and recognition with clear outcomes

• Ensuring growth opportunities for our people

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.