Utilization review nurse job description

You could be the one who changes everything for our 26 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity.
Monitor quality of care and collect and analyze utilization data

Serve as a resource between the health plan, provider relations, and dental providers

Review treatment plans and initial evaluations

Comply with performance measures in regards to denials and concurrent review timeliness

Develop and maintain collaborative relationships with providers and educate on levels of care

Position Purpose: To function as a dental services liaison between the Delaware Medicaid authority and Delaware First Health plan. Act as a point of contact and resolution as required. Additional responsibilities to include utilization review of dental services provided in provider offices, community health centers, hospitals, and out-of-network settings based on medical necessity, eligibility, and in accordance with contract language.

Experience: Graduate of accredited school of Dental Hygiene. 3+ years of utilization management or clinical experience in a dental office setting preferred. Previous experience documenting in Case Management or Utilization Management systems preferred.

Licenses/Certifications: Possess an active and unrestricted license as a Licensed Dental Hygienist to practice as a health professional in a state or territory of the United States. The license has a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review.

**Delaware only** : A dental services liaison who shall oversee and be responsible for all dental activities related to this Contract and serve as the main point of contact for DMMA regarding dental services.

Location: Prospective employee must reside in the state of Delaware.

Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

**TITLE:** Utilization Management Reviewer - Dental

**LOCATION:** Newark, Delaware

**REQNUMBER:** 1371287

Responsible for day to day activities including UR staffing, assignments and first line escalation for UR problem solving. Also accountable for leading daily UR and denial workflows. Intervenes with payers to prevent denial escalation. Completes any in house expedited appeals andmedical reviews for post claim audits. Serves as a resource for staff by providing education regarding CMS/payer regulations and standard work. Manages department data by producing monthly reports as designated by Regional Manager. The UR Team Lead works closely with the Physician Advisors, Regional UR Manager and Director and multidisciplinary team. Maintains confidentiality within the department as it relates to personnel matters.
ESSENTIAL JOB FUNCTIONS:

1. Directs the day to day activities of the UR Department and provides leadership on interdisciplinary committees and other organizational committees as assigned to by the UR Regional Manager.

2. Assists the Regional Manager in hiring, training, coaching, and evaluating of personnel.

3. Interacts with health care providers to identify medical necessity and appropriateness of admission to the inpatient setting and provides feedback to staff on appropriate documentation to support the need for admission.

4. Works with the team to ensure that financial reimbursement for Loyola Medicine is maximized through appropriate clinical documentation and timeliness of documentation.

6. Works with the FCC/Precertification Team to ensure that patients with complex diagnoses or care setting requirements are pre certified in accordance with payor requirements.

7. Maintains a strong relationship with insurance payers to facilitate discussions regarding authorization approvals.

8. Works in collaboration with the Revenue Cycle Team: FCC, HIM, Denials and Finance.

PROFESSIONAL DEVELOPMENT: All Registered Nurses are expected to engage in professional role activities, including leadership, appropriate to their education and position. Registered nurses are accountable for their professional actions to themselves, their healthcare consumers, their peers and to society. The UM Nurse is recognized as an expert in technical skills and professional practice.

The RN speaks up and uses resources to help evaluate situations where unethical behavior is in question. Consults other professionals to initiate ethical consults when needed. Works with a questioning attitude raises clinical concerns. Uses current literature to guide practice and offer ideas for improve practice and outcomes. Nurses implement practices that are congruent with cultural diversity and inclusion principles. The RN communicates effectively and speaks up when communication from others is not clear and may endanger safety of patients, families, groups, communities or colleagues. Effective verbal and written communication in the form of documentation in the medical record are essential to effective practice. Seeks assistance to resolve conflict if unable to resolve independently. Collaboration with the interdisciplinary team is essential in developing an effective plan of care. Nurses must collaborate inter and intra-professionally for effective practice. All nurses provide leadership within the practice setting. The level of leadership for a UR RN is consistent with the level of experience, knowledge and licensure. The UR RN effectively delegates to nurses, unlicensed assistive personnel and other disciplines as necessary to advance patient care. Effectively evaluates the completion of delegated care and provides feedback to unlicensed assistive personnel and other nurses. The UR RN continues to learn and develop competence that reflects current nursing practice. Completion of assigned learning materials and competency activities is expected within orientation and beyond. Nurses seek feedback to improve performance and raise questions when unsure of the correct path for patient care or professional performance. The UR RN is expected to contribute to the professional growth of others by acting as a preceptor, clinical coach and mentor.


Our Commitment to Diversity and Inclusion


Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

Responsible for providing utilization review and coordination of care throughout the healthcare continuum to promote quality and cost effective care to the members.
**Required Qualifications:**

+ Nursing school graduate.

+ California Registered Nurse License upon hire.

+ 3 years experience in utilization management and/or case management.

+ 3 years Clinical experience in hospital or medical office/clinic setting.

+ Experience with Milliman criteria.

**Preferred qualifications:**

+ Bachelor's Degree in Nursing or related field.

+ Certification in Case Management (CCM) upon hire.

Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.

**About Providence**

At Providence, our strength lies in Our Promise of "Know me, care for me, ease my way." Working at our family of organizations means that regardless of your role, we'll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

**Requsition ID:** 127296
**Company:** Providence Jobs
**Job Category:** Health Information Management
**Job Function:** Revenue Cycle
**Job Schedule:** Full time
**Job Shift:** Day
**Career Track:** Nursing
**Department:** 7520 OTHER ADMINISTRATIVE SERVICES CA PSJMC FULLERTON
**Address:** CA Anaheim 200 W Center St Promenade

Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.