Utilization Management Coordinator - LHB

At Luminare Health , our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.

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Job Summary

Job Responsibilities:

• Performs prospective, concurrent, and retrospective reviews to ensure the medical necessity and appropriateness of all hospital admissions and continues stays utilizing nationally recognized medical management criteria.
• Performs discharge-planning coordination unless this function is performed by a RN Care Manager, Case Management.
• Identifies alternative care interventions based on quality of care and cost effectiveness and communicates these options to the attending physician.
• Performs certification of outpatient surgeries and treatment.
• Performs prospective, concurrent and retrospective review of ancillary services.
• Conducts mandatory and discretionary second surgical opinion process.
• Refers all cases that do not meet applicable criteria or need a plan of care review to a Physician Advisor.
• Assists with the orientation of new Healthcare Management personnel and contributes to the ongoing networking of expertise with co-workers.
• Acts as a resource for peers and all other associates and clients.
• Performs medical claims review as required.
• Makes recommendations for system development from a user’s perspective.
• Assists in the preparation of reports that analyze and track quality of service and utilization statistics.
• Assists in special projects.
• Maintains a focus on timely customer service.
• Complies with Healthcare Management policies and procedures and conforms to the current URAC Utilization Management Standards while performing the job function.
• Reviews and completes the Corporate Confidentiality Attestation at the time of employment and routinely with periodic monitoring.
• Reviews and completes the Corporate Conflict of Interest Attestation at the time of employment and routinely with periodic monitoring.
• Maintains active state nursing license and continuing education requirements.
• Other duties as assigned by a Healthcare Management Supervisor or Director of Healthcare Management.
• Conforms to the requirements of the Corporate Code of Conduct.
• Complies with Healthcare Management Policies & Procedures while performing the job function.
• Promptly review, complete and acknowledge educational activities, which may include webinars, educational articles, etc. on an ongoing basis to comply with HCM continuing education requirements.
• Prioritize daily work assignment to meet division goals and customer requirements.
• Participates in Quality Improvement initiatives.
• Collaborate as necessary with internal and external customers to achieve excellent service results.
• Represents the Healthcare Management Division internally and externally with professionalism and demonstrated effectiveness.
• Acts as a resource to colleagues and all other associates and clients.
• Other duties and special projects as needed/assigned by HCM Management.

Required Job Qualifications:

• Unrestrictive Registered Nurse issued by a state or territory of the United States of America.
• Nurse with a minimum of two years clinical nursing and/or managed care experience.

Please note while this position is remote, candidates must live in IL, IN, IA, KS, MO, MT, NM, NC, OK, PA, TX or WI to be considered.

General Abilities/Competencies:

• Communicate in a positive and effective manner in both oral and written communication;
• Read and interpret documents, criteria, instructions, and policy & procedure manuals;
• Write/create routine correspondence and reports;
• Speak effectively with clients, physicians, providers, families in crisis and community agencies as well as co-workers and senior management;
• Add, subtract, multiply and divide in all units of measure, using whole numbers, common fractions and decimals;
• Compute rate, ratio and percent;
• Apply common sense understanding to carry out instruction furnished in written, oral or diagram form;
• Deal with problems involving several concrete variables in standardized situations;
• Evaluate problems, develop alternative solutions and identify trends and patterns;
• Capable of working in an environment that requires organization and prioritization in order to address time sensitive assignments;
• Excellent interpersonal skills;
• Perform multiple tasks simultaneously;

Preferred Job Qualifications:

• Prior Utilization Management or Case Management experience preferred

Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!

EEO Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.

Pay Transparency Statement:

At Luminare, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for associates.

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

Min to Max Range: