Utilization Management Nurse

Intus Care is seeking a dynamic and experienced Utilization Management Nurse. This position will work with Intus Care PACE Program customers to streamline communication with and between the PACE provider network, Medical Director, Interdisciplinary Team, and the finance team. Ensuring efficient service authorization and documentation of appropriate and high-quality services that are aligned with the participants' needs and goals of care. This position will be responsible for managing and overseeing communication processes and decision-making regarding participant service review and authorization, ensuring consistent and accurate documentation throughout the care cycle that supports appropriate payment of service claims.

What We Do:

In This Role You Will:

• Rigorous adherence to PACE program service authorization policies, ensuring that participant care and related claims are:
  • Reasonable and necessary for diagnosis or treatment and consistent with PCP coordination decisions.
  • In accordance with accepted medical standards and consistent with the participant care needs including level of care and advanced care planning principles.
• Active involvement in various aspects of the utilization management process, including:
  • Concurrent review of all hospital admissions (observation and inpatient) with the Interdisciplinary Team driving efficient and timely transitions of care, retrospective review of inpatient admissions under 48 hours, and claims submitted inconsistent with the service authorization.
  • Concurrent review of all subacute and SNF admissions with the Interdisciplinary Team driving efficient and timely discharge plans and transitions of care.
  • Coordination and review of all other services delivered by contracted providers and identified by the PACE program assuring consistency with Interdisciplinary Team service authorization, care plans, and PCP coordination decisions.
• Appeal Management - In cases of claim rejection, the Intus Care Utilization Management Nurse will lead the provider appeals process. Responsibilities Include:
  • Comprehensive review of provider network appeals.
  • Collaboration with the PACE Program's Medical Director to review and respond to appeal requests, ensuring issuance of a written determination consistent with the PACE program policies.

Qualifications:

• 3 to 5 years of utilization management experience.
• Current RN license
• Proven experience working in risk based integrated models of care.
• Ability to use data to drive decisions and collaboration with internal and external stakeholders.
• Strong strategic thinking, problem solving, and decision making skills.
• Excellent communication and leadership abilities, capable of motivating and guiding teams toward timely and efficient care management strategies

What We Offer:

• A chance to be a part of a trailblazing team in healthcare technology.
• Competitive salary package.
• Comprehensive benefits including health, dental, and vision insurance.
• A collaborative, inclusive, and dynamic work environment.
• Opportunities for professional growth and development.

Company Core Values:

• Take Ownership For Your Responsibilities and Outcomes
• Think With Data First
• Be Passionate About Impact
• Take Strides Toward Growth and Innovation
• Be Supportive Of Each Other
  

Salary Range: $85,000-$100,000/year
Location: Remote Eligible