• 15284OverviewPRNHours - Day/Afternoon/Weekends; Must be willing to work 2-3 days per week and assist in covering vacations during winter/summer break.Remote, with opportunity to come into Corporate Office (Downers Grove) for monthly meetings and training.The Utilization Management Nurse is responsible for following inpatient, skilled nursing facility, acute rehab, long term acute care and home health cases to ensure that criteria is met, length of stay is appropriate, and discharge needs are in place, while staying within the parameters of compliance and regulatory requirements.Responsibilities• Performs initial and concurrent review on inpatient, skilled nursing facility, acute rehab, long term acute care and home health cases. Determines medical necessity by application of criteria per Milliman Care Guidelines, Utilization Management Department Policies, specific Health Plan guidelines, and CMS regulations. Recommends an increase or decrease in level of care/equipment/service based upon medical condition and physician orders.• Refer all services that do not meet established criteria, to the Medical Director. Notify all parties of Medical Director determinations, and communicate alternate service options when indicated.• Responsible for the assessment of the member’s and family’s psychosocial, medical and educational level in conjunction with hospital staff to assist in the discharge planning of hospitalized patient. This includes providing authorization for needed services through vendors in accordance with payer networks. Monitor ongoing planning process with medical team to ensure positive outcomes and timely transition to the next level of care. This concurrent evaluation will determine plan effectiveness of reaching the desired goals and outcomes. Document all pertinent information obtained through discussion with providers, patients, family members and other health care professionals in the EPIC tapestry record.• Through the discharge planning process, helps identify members who have ongoing case management needs, and refers these members to the Case Management team for outreach and follow up.• Work with the Medical Director and peers to resolve patient care problems and physician-related issues• Coordinate and document the investigation of all potential quality of care/service issues in accordance with established policy and procedure. Report findings to the UM/QA Committee and appropriate parties• Support all Internal Quality Assurance initiatives developed for the Utilization Management Department. Report problems and negative patterns to the Manager and work with the manager to develop corrective action plans• Serve as one of the “On-Call Nurses” according to established policies and procedures• Participates in the preparation of all Health Plan audits• Run reports, as needed, to review and analyze client data (i.e. Days/K, Admits/K, ALOS).• Act as a resource for Utilization Management staff, providers, clinic staff, patients and family members. Responsible for the assessment of the individual’s and family’s psychosocial, medical and educational level to plan specific objectives and goals in a time specific action plan. Implement the action plan within a specific time frame with a multi-medical disciplinary team.• Represent Department on committees as requested.• Provide support as needed for special projects.• Attend monthly client Utilization Management Committee meeting(s) as assigned. Prepare monthly Utilization Management statistics and discuss cases, at the Utilization Management Committee meeting, that result in an increased length of stay due to medical complexities.• Perform other projects and duties as related to department objectives.• Enhance and maintain current knowledge of health care and managed care.• Maintain confidentiality of all information as stipulated in the confidentiality policy.• Demonstrate an understanding of the departmental goals, company values and corporate mission statement through everyday attitude and behavior.• Must be able to get along with others, to be a team player, to accept constructive criticism from your manager and be able to follow work rules.• Perform all other duties/responsibilities as assigned.QualificationsKNOWLEDGE SKILLS AND ABILITIES:• Knowledge of Milliman Care Guidelines or application of criteria to determine medical necessity. Prefer experience in pre-certification process with capitated health plans. Familiarity with EPIC or other electronic medical record a plus. Experience within a multi-tasking environment helpful.EDUCATION and / or CERTIFICATION/LICENSURE:• Associate/Diploma/Baccalaureate degree in nursing, 2+ years of bedside nursing in a hospital setting.EXPERIENCE:• Two consecutive years of experience in concurrent Utilization Review in a Health Plan or hospital setting with HMO and Medicare Advantage population. Case Management Certification a plus, (CCM or ACM).The compensation for this role includes a base pay range of 32.65-49, with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package.